Get Medical Records Release Form - Pdf - Fichte, Endl & Elmer Eyecare

Filling out the Medical Records Release Form for Fichte, Endl & Elmer Eyecare is an important step in managing your healthcare records. This guide provides clear instructions to help you navigate the process efficiently online, ensuring that your information is accurately submitted.

Follow the steps to complete the form successfully:

1. Click ‘Get Form’ button to obtain the Medical Records Release Form and open it in your preferred PDF editor.
2. Begin by entering your name in the designated field. Ensure that you provide your full name as it appears in your medical records.
3. Next, input your date of birth in the specified format. This information helps to verify your identity.
4. Provide your telephone number in the space provided. Include your area code for accuracy.
5. Fill in your street address, including any apartment or unit number if applicable, followed by your city, state, and zip code.
6. Indicate the specific information you wish to have released by checking one of the options: 'All Clinical Medical Records' or 'All Records – Please list...' If you opt to list additional records, provide clear details in the space provided.
7. Review the section regarding sensitive information, such as mental health or substance abuse records. Decide whether you consent to have this information released by checking the appropriate box.
8. Provide your signature and date on the form to authorize the release. If you are a parent or legal guardian, ensure you indicate this clearly.
9. If the records contain information concerning HIV testing or AIDS diagnosis, you must also consent by checking the appropriate box and signing again.
10. Note the validity period for the authorization and provide your signature and date, indicating your understanding of this condition.
11. Fill in information for the recipient of the records by entering their name, telephone number, fax number, street address, city, state, and zip code.
12. Once all fields are completed, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Start managing your medical records by filling out the form online today.