Get 1. Welcome Page

Completing the 1. Welcome Page is an essential step in initiating the authorization for the release of medical records. This guide will provide clear instructions for filling out this form online, ensuring you provide all necessary information correctly.

Follow the steps to fill out the 1. Welcome Page accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. In the section labeled 'Where are the records being released from?', fill out the facility name and provider name(s). Include the complete address, city, state, and any relevant contact information.
3. Provide information about the patient in the designated fields. Enter the patient's name, date of birth (DOB), and the Social Security Number (last four digits will be formatted as XXX-XX-____). Additionally, fill out the email address, mailing address, city, state, phone number, fax number, and zip code.
4. Indicate where the medical records are being sent by providing the recipient's name, email address, and full mailing address including city, state, phone number, fax number, and zip code.
5. Next, select the types of records you would like released by checking all applicable boxes. Options include all records, office/clinic notes, operative reports, and various other types as listed. You may also specify particular dates for the records.
6. If there are specific portions of the medical records you wish to exclude from the release, mark the categories you would like to keep confidential.
7. Select the purpose of the disclosure by checking the relevant option, such as personal use, litigation/legal, insurance, continuation of care, or transfer to a new physician.
8. Choose the desired delivery method for the records by selecting one of the available options: email, fax, pick-up at MediCopy, or postage (note that an additional fee may apply for postage).
9. Signature is required in the section for the patient's authorization. Sign and date the form, and specify your relationship to the patient if applicable.
10. Finally, review all entered information for accuracy, then save changes, download, print, or share the completed form as necessary.

Complete your documents online today for a hassle-free submission.