Get Authorization-to-release-medical-records-to-graybill

Filling out the Authorization-to-Release-Medical-Records-to-Graybill form is a straightforward process that enables users to grant permission for their medical records to be shared. This guide will provide clear instructions to help you complete the form effectively and efficiently.

Follow the steps to complete the authorization form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In the section labeled 'FROM,' enter the name of the disclosing physician or health care provider who will release your medical records.
3. Fill in the 'TO' section with the name of Graybill Medical Group as the receiving physician or health care provider.
4. Complete the address fields, including the specific address, city, state, and zip code of both the disclosing and receiving providers.
5. In the 'Release records and information regarding' section, enter the patient's name, followed by their date of birth, social security number, telephone number, and full address.
6. Specify the duration of this authorization. It will remain effective until a specified date or for one year from the date you sign, if no date is entered.
7. Review the 'Revocation' and 'Redisclosure' sections, understanding your rights regarding the release of your health information.
8. Indicate the types of records you are authorizing for release by checking the appropriate boxes (e.g., Medical Information, X-Ray, Psychiatric Information, etc.).
9. Sign and date the authorization at the bottom of the form. If you are signing on behalf of the patient, specify your relationship to the patient.
10. Finalize your document by saving changes, and if needed, download, print, or share the completed authorization.

Complete your Authorization-to-Release-Medical-Records-to-Graybill form online today for efficient processing.