Get Request For Release Of Medical Records 2doc Ltpgtsample Authorization To Release Medical Records

Filling out the REQUEST FOR RELEASE OF MEDICAL RECORDS form is an important process for ensuring your medical information is shared with the appropriate healthcare providers. This guide will provide you with step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to complete the form without errors.

1. Click the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In the first section of the form, enter the name of the healthcare provider or center that you are authorizing to receive your medical records. In this case, write 'Provision Eye Center'.
3. Below the name of the healthcare provider, fill in the names of the doctors involved — 'Scott Durrett, MD' and 'Robert Daddario, OD'.
4. Provide the address of the Provision Eye Center: '1191 Jacaranda Blvd., Venice, FL 34292'.
5. Next, in the contact information section, fill in the phone numbers: '(941)493-0311' and '(941)492-4655'.
6. In the 'Requested from' section, specify the name of the physician or healthcare provider from whom the medical records will be released. Ensure to include their address, city, state, and zip code.
7. Indicate the physician's phone and fax numbers in the corresponding fields.
8. Review the paragraph detailing the types of records to be released. It lists various types of medical records, including those related to mental health and substance abuse. Cross out any specific information you do not wish to include.
9. In the patient identification section, fill out your full name, social security number, and date of birth.
10. Sign the form where indicated, and if necessary, have your legally authorized representative sign it as well. Finally, date your signature.
11. After completing all the sections, save your changes. You may then download, print, and share the form as required.

Complete your documents for medical record release online today!