Get Nc Michael D. Altheimer Authorization For Release Of Medical Records 2015-2025

Completing the NC Michael D. Altheimer Authorization For Release Of Medical Records form online can facilitate the efficient transfer of your medical information. This guide provides comprehensive steps to ensure that you fill out the form accurately and completely.

Follow the steps to successfully complete the authorization form.

1. Click the ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by entering the patient's name in the designated field. Ensure that you accurately type their full name as it appears in their medical records.
3. Input the patient's date of birth in the specified field. This should correspond with the patient's official records to avoid any discrepancies.
4. Fill in the patient's complete street address, including the city, state, and zip code. Accurate contact information is essential for the processing of the request.
5. Provide the patient's daytime phone number in the required format. This may help facilitate any follow-up calls if necessary.
6. In the section labeled 'I Authorize,' write the name of the doctor or medical facility that you are requesting to release the medical records. Include their specialty and contact information as prompted.
7. Specify whom you are authorizing to receive the medical records by filling in their name, specialty, and contact details as required.
8. Choose the option that best suits your needs regarding the records you wish to have sent, such as 'All records for the past 3 years' or 'Records from specific dates.' If you select specific labs or imaging reports, be sure to fill in the required sections.
9. Indicate the purpose for the release of the medical records by checking the appropriate box. This could be for continuation of care, patient request, transfer, and other outlined purposes.
10. Acknowledging that the authorization can include sensitive information, indicate any exceptions for the release of specified types of medical information by checking the relevant boxes.
11. Complete the authorization by signing the document in the designated space. If you are not the patient, provide your relationship to the patient for clarity.
12. Date the form after completing the signature. Ensure that all information is accurate before finalizing the form.
13. Once you are satisfied with the completed form, you can save your changes, download the document, print it for physical submission, or share it according to your preference.

Make sure to complete your documents online for a smooth experience.