Get Patient Medical Records Access, Release And Authorization Form - Memorialcare

This guide provides clear instructions on how to accurately complete the Patient Medical Records Access, Release and Authorization Form for Memorialcare. It is designed to assist users in navigating the form's components with ease.

Follow the steps to effectively complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling in the patient's name at the top of the form. Ensure the name is spelled correctly for accurate record retrieval.
3. Enter the date of birth (DOB) in the designated field. Use the format specified on the form to avoid any discrepancies.
4. Fill in the patient's address, including street, city, state, and zip code. This information is crucial for mailing the records.
5. Input the medical record number if available, as this helps the facility locate the specific patient information swiftly.
6. Provide a phone number where you can be reached. This could be necessary for any follow-up regarding the request.
7. Indicate the date of service (DOS) for the records you are requesting. This helps narrow down the records needed.
8. Select the type of record requested by checking the appropriate box. Make sure to specify if charges will apply for a second set of records.
9. If you prefer the records to be sent to a medical facility or physician, complete the designated section with their name and address.
10. If the patient is unable to sign the form, indicate the reason and fill in the signer's information accordingly.
11. The signer should provide their signature and print their name below, along with the date of signing. A witness must also sign, if required.
12. Finally, confirm whether you would like a copy of the authorization for your records. Select 'Yes' or 'No' as per your preference.
13. Once all sections are completed, save your changes. You may then download, print, or share the form as needed.

Complete your Patient Medical Records Access, Release and Authorization Form online for fast and efficient processing.