Get Medical Record Release Form - Rego.doc. Hotel & Travel Services

Filling out the Medical Record Release Form accurately is essential to ensure that your health information is disclosed appropriately. This guide provides step-by-step instructions to help you complete the form easily and correctly.

Follow the steps to complete the Medical Record Release Form.

1. Click the ‘Get Form’ button to obtain the form and open it in an editable format.
2. In the first section, fill in the patient’s name, date of birth (DOB), and Social Security number (SS#). This information is vital for identifying the correct medical records.
3. Next, complete the address section by providing the street address, city, state, and zip code of the patient. Ensure that this information is accurate to avoid any complications in record retrieval.
4. In the 'Information to be disclosed' section, specify the exact information and the dates you wish to be released. It is important to be as detailed as possible to ensure you receive the correct records.
5. Review the statement regarding potential sensitive information, including details related to drug and alcohol treatment, mental health, and other conditions. If you do not want this information released, please initial in the indicated area.
6. The next field requires a signature from the patient, guardian, or authorized representative. Provide the signature and ensure it matches the name used earlier in the form.
7. Enter the date when the form is being signed in the designated area.
8. Fill in the name of the person or agency to whom the records should be released. For this form, it is 'Ramon Rego, MD, EMO Medical Care, 369 Springfield Avenue, Berkeley Heights, NJ 07922.'
9. Once you have completed all fields, review the form for accuracy. Then, you can save the changes, download the document, print it for your records, or share it as necessary.

Complete your documents online for efficient processing and record management.