Get Mt Request For Deceased Patient Records

Completing the MT Request For Deceased Patient Records is a vital step in obtaining important health information for a deceased individual. This guide aims to provide clear and supportive instructions to help users navigate the process effectively.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the necessary form and open it in an accessible format.
2. Enter the name of the deceased individual, including any maiden names or known aliases in the designated field.
3. Provide the date of birth (D.O.B) and the date of death (D.O.D) for the deceased in the respective fields.
4. Fill in your own name in the 'Name of Person Requesting Records' field.
5. Indicate your relationship to the deceased individual in the 'Relationship to Individual' section.
6. Complete your address, including city, state, and zip code, in the appropriate fields.
7. Input your phone number so MSH can contact you if necessary.
8. Specify the date range for which you are requesting Protected Health Information (PHI) in the provided fields.
9. Select the types of records you are requesting by checking the corresponding boxes, such as 'Discharge Summary' or 'Laboratory Studies.'
10. Explain the purpose or need for this disclosure in the designated area.
11. Sign the form as the legally authorized representative and print your name where indicated.
12. Indicate the date on which you are executing the request.
13. Attach all required documentation that supports your legal authority to access the requested records.
14. Review the completed form for accuracy. Once verified, save changes, download or print the form for your records.
15. Mail the completed request and supporting documentation to the Health Information Department at Montana State Hospital.

Complete your document submission online today for efficient processing.