Get Holland Pediatric Associates, Plc Consent To Release Medical Information Patients Name: Date Of

This guide will assist you in completing the HOLLAND PEDIATRIC ASSOCIATES, PLC CONSENT TO RELEASE MEDICAL INFORMATION form with clarity and ease. By following the steps outlined below, you will ensure that your medical information is released accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to obtain the form and open it in the designated viewer.
2. Begin by entering the patient's name in the designated field at the top of the form labeled 'Patient’s Name'.
3. Next, specify the primary care physician by checking the appropriate box next to their name from the list provided.
4. Enter the patient's date of birth in the specified section for legal identification.
5. In the 'Release TO' section, fill in the required details for the new doctor or facility including name, office, address, and phone number. Ensure all starred items are completed.
6. Indicate how the records will be released by selecting the appropriate box: either for pick-up or mailing.
7. For medical information to be released, choose one of the options regarding the content of the records, including whether to include or exclude sensitive information.
8. State the reasons for releasing records by checking the applicable box or specifying other reasons as necessary.
9. If the patient is 18 years of age or older, ensure the patient signs the form. Otherwise, a parent or legal guardian must sign, provided they have legal guardianship documentation.
10. Complete the signature section with the signature of the person authorizing the release, printed name, relationship to the patient, and their phone number. A witness signature is also required.
11. Finally, review all completed sections for accuracy, then save changes, and download, print, or share the completed form as needed.

Complete your documents online today and ensure a smooth process for releasing your medical information.