Get Medical Record Request Information - Shady Grove Fertility

Filling out the Medical Record Request Information form is an essential step for users who wish to obtain their medical records efficiently. This guide provides a detailed, step-by-step approach to help you navigate the process smoothly and understand each section of the form.

Follow the steps to complete your medical record request online.

1. Click the ‘Get Form’ button to access the Medical Record Request form and open it in your preferred document editor.
2. Begin by filling out the patient’s full name at the top of the form. This ensures that your request is processed correctly.
3. Next, provide the patient's street address, city, state, and zip code. Accurate contact information is vital for receiving your records.
4. Enter the patient's date of birth in the specified format (Mo/Day/Yr) and their Social Security number. This information helps verify the identity of the requester.
5. Indicate a daytime phone number where you can be reached for any follow-up questions.
6. Identify the records you wish to request by checking the relevant boxes, such as history and physical, progress notes, operative reports, etc.
7. If you require the release of sensitive information, initial the corresponding box indicating your authorization for such records.
8. Specify the name of the company, agent, facility, or person to whom the records should be sent.
9. Complete the address section for the recipient of the records, ensuring it includes the street, city, and zip code.
10. If self-delivery applies, provide your email address, but note that records can only be emailed to the patient themselves.
11. State the purpose of the disclosure to clarify why you are requesting your health information.
12. Sign and date the form to authorize the request. Ensure that you provide a daytime phone number for any potential follow-up.
13. Finally, you can save changes, download, print, or share the completed form according to your preferred method of submitting it.

Submit your Medical Record Request Information form online today for prompt processing and access to your health records.