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  • Medical Records Request And Release Form - California State ...

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Any healthcare facility to release medical information. The patient must be specific as to the nature of the information he/she would like released and the purpose for which it is requested. Please initial options. DATE: (Please Print) LAST NAME FIRST NAME MI DATE OF BIRTH ID#.

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Write the name of your child's doctor and any other medical providers or facilities. Provide a phone number and location where you can be contacted. If possible, provide an alternate phone number as well. At the bottom of the release, provide your name, home address and date and sign the paper.

Yes, HIPAA Requires Medical Records to Be Emailed to Patients if Requested.

The patient's full name and address. Name of the medical practice releasing the information. Name of the individual or facility to receive the information. Specific information to be released. The purpose of or need for the information. Method of release of the information.

Dear [Recipient's name], I am writing you to request copies of my medical records. I was treated in your office on [xx/xx/xxxx]. Please include all of my charts, test results, and consultation notes including referrals regarding my medical care.

A medical release form is a document that gives healthcare professionals permission to share patient medical information with other parties. Under HIPAA regulations, it's referred to as an authorization.

Please call (916) 650-0490 for further information. If none of these circumstances apply, please complete the form. To continue with your request for access to your Medi-Cal records, please go to page 2 and indicate which records you wish to get a copy of.

A Medical Records Release Form (also known as a Medical Information Release Form) is a form used to request that a health care provider (physician, dentist, hospital, chiropractor, psychiatrist, etc.) ... The automated form allows you to request information to be sent to multiple individuals and organizations at once.

A HIPAA medical release form must contain the following: A description of the PHI that may be shared or disclosed. The purpose for the PHI disclosure. The name of the entity or person(s) with whom the PHI will be shared.

No Compound Authorizations. ... Core Elements. ... Required Statements. ... Marketing or Sale of PHI. ... Completed in Full. ... Written in Plain Language. ... Give the Patient a Copy. ... Retain the Authorization.

Patient requests must be written without requiring a "formal" release form. Include signature, printed name, date, and records desired. Release a copy only, not the original. The physician may prepare a summary of the medical record, if acceptable to the patient.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232