Get Authorization To Release Medical Records - Valley Forge Ob/gyn

This guide will provide you with clear, step-by-step instructions on completing the Authorization To Release Medical Records form for Valley Forge OB/Gyn. Understanding how to properly fill out this form ensures that your medical records are accurately shared with the designated recipient.

Follow the steps to fill out the form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal information in the Patient Information section. Fill in your name, address, telephone number, date of birth, last four digits of your Social Security number, city, state, and zip code. If you have previously gone by another name, include that under Previous Name.
3. In the Information to be Released From section, provide the entity or person that currently holds your medical records.
4. In the Information To Be Sent To section, fill in the name and address of the individual or organization that will receive your medical records.
5. Select the type of information you wish to be released by checking one of the options under Information To Be Released—either 'All Medical Records' or 'Specific information.' If you select specific information, please specify what information you are requesting.
6. Indicate the Purpose For Which The Disclosure Is Being Made by checking the appropriate option, such as 'Transfer' or 'Other.' If checking 'Transfer,' provide a reason for the transfer in the space provided.
7. Review the Patient Authorization section. By signing, you acknowledge the potential inclusion of sensitive information within your records and authorize the release of these records. If you wish to exclude specific information such as drug/alcohol abuse or mental illness records, please initial next to the corresponding statements.
8. Read through My Rights to understand that signing this authorization is not a condition for receiving healthcare benefits and that you have the right to revoke this authorization in writing.
9. Sign and date the form at the bottom, ensuring that the signature is from the patient, guardian, or an authorized representative.
10. Once you have completed all sections, save your changes, download the form, print it, or share it as needed.

Start filling out your Authorization To Release Medical Records online today!