Get Authorization To Release Medical Records From Another Person Form 110712.doc

This guide provides step-by-step instructions for filling out the Authorization To Release Medical Records From Another Person Form 110712.doc online. Follow these directions to ensure that you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly:

1. Click the ‘Get Form’ button to access the form and open it in your preferred online form editor.
2. Enter the patient’s full name in the designated field.
3. Provide the patient’s date of birth in the appropriate section.
4. Fill in the patient’s social security number (SS#) as required.
5. Complete the patient’s address, including the city, state, and zip code.
6. Insert the patient’s telephone number and any additional contact number.
7. In the section titled 'To Whom it May Concern', list the name and city of the physician or entity that will receive the records.
8. Specify the type of medical records to be released by checking the appropriate boxes that apply.
9. If applicable, provide the specific time frame for records release by entering the dates in the indicated fields.
10. Indicate any particular medical conditions related to the records if necessary.
11. Initial to consent to the release of HIV/AIDS-related information if relevant.
12. List the name of the person or group who will receive the medical records.
13. Explain the reasons or purposes for obtaining the medical records in the text field provided.
14. Sign and date the form, ensuring the signature is that of the patient or legally authorized person.
15. Specify the expiration date or event for this authorization.
16. Review all the entered information for accuracy before finalizing.
17. Once completed, save changes, and then choose the option to download, print, or share the form as needed.

Complete your document online today to streamline your medical records release process.