Get Urgent Care Release Form

Filling out the Urgent Care Release Form online is a straightforward process that helps facilitate the transfer of your medical records. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the form online with ease.

1. Press the ‘Get Form’ button to access the Urgent Care Release Form and open it in your preferred editor.
2. In the first section, enter your personal information, including your name, street address, telephone number, date of birth, city, social security number, and state/ZIP code.
3. Next, indicate whether you are requesting the transfer of your medical records from Stafford Urgent Care / Stafford Primary Care or if you are allowing them to receive records from another entity. Fill in the name and organization of the receiving party, along with their address and contact information.
4. Specify the types of information to be released by selecting the appropriate checkboxes for items such as physician's progress notes, discharge summaries, laboratory results, and other medical records. If there are additional records that need to be specified, use the provided space to list them.
5. Provide the dates of service relevant to the request by filling in the start and end dates.
6. Select the purpose for the disclosure of the information, including options like continuing care, personal use, or providing a specific reason in the given space.
7. Carefully read the authorization statement provided, then sign and date the form in the designated fields. If applicable, a parent, guardian, or designated representative should also sign the form.
8. Finally, ensure all information is accurate, then choose to save changes, download, print, or share the completed Urgent Care Release Form as necessary.

Take the next step and fill out your documents online today.