Get Release Of Records Bformb - Sumner Pediatrics Bpcb

This guide will provide you with a clear and comprehensive approach to filling out the release of records form for Sumner Pediatrics, PC online. Following these steps will help you ensure that all required information is accurately provided.

Follow the steps to complete the release of records form online.

1. Press the ‘Get Form’ button to access the release of records form and open it for editing.
2. Begin by entering the patient's date of birth in the designated field. This helps to identify the individual whose records are being requested.
3. Provide the patient's telephone number to facilitate communication regarding the records.
4. Enter the full name of the patient in the specified section. This should match the name in the official health records.
5. If you are not the patient and are authorizing the release, complete the section that asks for your name and your relationship to the patient.
6. In the fields provided, fill in the name and contact details of the entity to whom the records will be disclosed. Make sure to include their address, attention line (if necessary), and phone number.
7. Select the types of protected health information that you are authorizing for release. Check the relevant boxes for medical records, immunization records, or other specified information.
8. Indicate your approval for the disclosure of sensitive information, such as mental health, substance abuse, or HIV/AIDS/STD information by checking the applicable boxes.
9. Review the fees associated with obtaining the records and check the appropriate boxes indicating the services you require for the release.
10. Provide the mailing address for where the records should be sent, if applicable.
11. Print the name of the person requesting the records in the designated area and enter the date.
12. Sign the form to authorize the release of protected health information, indicating whether you are the patient, guardian, or legal representative. Don’t forget to date your signature.
13. Fill in the form of payment and the amount to be charged, if applicable. This finalizes the transaction for the requested records.
14. Once you have completed the form, review all entered information for accuracy before saving, downloading, printing, or sharing as needed.

Complete your release of records form online now.