Get Request For Protected Health Information - Hooksett Fire Department - Hooksettfire

Filling out the Request For Protected Health Information form is a crucial step in obtaining your medical records from the Hooksett Fire Department. This guide will provide you with clear and detailed instructions to ensure that the process is seamless and straightforward.

Follow the steps to accurately complete your request form online.

1. Click ‘Get Form’ button to initiate the process of acquiring the Request For Protected Health Information form. This action will allow you to access the form in a convenient online format.
2. Begin by entering the patient's name in the designated field, ensuring it is spelled correctly to match official records.
3. Fill in the date of birth for the patient, which helps to verify their identity.
4. Provide the patient's current address, including street, city, state, and zip code.
5. Indicate the date(s) of care for which the medical records are being requested. This helps in retrieving the relevant documents.
6. In the representative section, fill out the name and address of the person to whom the records should be sent, if applicable.
7. Select the specific record(s) you are requesting by marking the appropriate checkbox, such as a complete medical record, face sheet, or billing report.
8. Sign and date the form to authorize the release of the medical records. If you are signing on behalf of the patient, ensure you indicate your relationship to them.
9. If you wish, write a note specifying any additional instructions or details regarding the request.
10. Review the form for accuracy, then save changes. You can choose to download, print, or share the completed form as needed.

Start completing your Request For Protected Health Information form online today.