Get Phc-mr091 Regional Authorization For The Release Of Health Records R Aug 26-15.doc

This guide provides a comprehensive step-by-step approach to filling out the PHC-MR091 Regional Authorization For The Release Of Health Records form online. By following these instructions, users can ensure that their requests for health records are processed smoothly and efficiently.

Follow the steps to complete your authorization form correctly.

1. Click ‘Get Form’ button to obtain the authorization form and open it in your editor.
2. In Part 1, provide the patient’s information, including their last name, first name, mailing address, and date of birth. Ensure all details are accurate to avoid processing delays.
3. Move to Part 2 and check the appropriate boxes to indicate the types of records requested, such as visit summaries or diagnostic reports. If exact dates are unavailable, provide the best estimates.
4. Complete Part 3 by specifying who will receive the records. Include either your own information or that of the designated individual. Ensure to provide a valid mailing address and contact number.
5. If you are 12 years of age or older, complete Part 4 by signing and dating the section to authorize the release of records.
6. For patients under 12 years old or those unable to authorize themselves, fill out Part 5. Clearly state your relation to the patient and provide necessary documentation if required.
7. Once all parts are completed, save the form. You can then download, print, or share the completed document as needed.

Complete your health records authorization form online today to ensure your request is processed promptly.