Get 855 764 2382

Filling out the 855 764 2382 form for the release of medical information is essential for ensuring proper continuity of care. This guide will walk you through each section of the form to facilitate a smooth filling experience, especially when completing it online.

Follow the steps to successfully fill out the 855 764 2382 form online.

1. Click the ‘Get Form’ button to access the 855 764 2382 form in the online editor.
2. In Section A, provide your birth date, social security number (optional), and patient name. This information is crucial for identifying the medical records to be released.
3. Fill in the provider's name as 'Redmond Regional Medical Center' and their address at '501 Redmond Rd, Rome GA 30165.' Be sure to double-check for accuracy.
4. Complete the recipient information by entering their name, address, phone number, and fax number. This should be the person or entity that will receive the medical records.
5. Specify when the authorization will expire. Indicate either a specific date or an event, but not both.
6. Select the purpose of the disclosure by checking the relevant box(es) such as 'Continuity of Care,' 'Personal health record,' or any other applicable reason.
7. Indicate the information that needs to be disclosed. You can choose from various options such as discharge summary, operative report, or all records. List any additional details as necessary.
8. If applicable, initial the section acknowledging that the released information may include sensitive information and check the box if this does not apply to you.
9. Read the understanding section carefully and sign to confirm your consent for the release of information.
10. If applicable, complete Section B regarding marketing purposes, otherwise proceed to Section C.
11. In Section C, provide your signature, print your name, and indicate your relationship to the patient if you are not the patient.
12. Once all sections are complete, review your entries for accuracy, and then you can save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure seamless access to your medical records.