Authorization to release medical records

    • [PDF File]AUTHORIZATION TO RELEASE CONFIDENTIAL MEDICAL …

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      A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally …

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    • [PDF File]MediCopy Authorization for the Release of Medical Records

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      I hereby authorize MediCopy and its affiliates to release or disclose to the person(s) or organization listed above, all medical records requested, including any specially protected records such as those relating to psychological or psychiatric impairments, drug abuse, alcoholism, sickle cell anemia or HIV infection, unless otherwise noted ...

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    • [PDF File]MEDICAL RECORDS RELEASE OF INFORMATION …

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      Sep 29, 2021 · MEDICAL RECORDS RELEASE OF INFORMATION AUTHORIZATION FORM . Mail Request To: Athletico Medical Records • 2122 York Road, Ste.300, Oak Brook, IL 60523 . Email: medicalrecords@athletico.com • Phone (630) 280-2812 • Fax (630)280-2912 . Patient Name: Date of Birth: Address: Phone: Email:

      release of medical information form

    • [PDF File]AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

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      AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION HIM_ROI Approved by Director of Finance 11/27/2018; rev. 1/4/2019 GUIDELINES FOR COMPLETING “AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION” FORM Name of Patient: Legal name of patient. Date of Request: The date information is requested from Hannibal Clinic or the date that Hannibal

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    • [PDF File]AUTHORIZATION TO RELEASE MEDICAL RECORDS PATIENT ...

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      AUTHORIZATION TO RELEASE MEDICAL RECORDS PATIENT INFORMATION (Please Print): ... Medical Records Coordinator Phone: 207-563-3366 Ext 7 80 River Road Fax: 207-563-3393 Newcastle, ME 04553 REASON: Selected new physician in the area Other _____ Change of insurance Moving out of town ...

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    • [PDF File]AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

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      Please initial on each line below to include these specific records in this release. I understand that failure to initial the three (3) items below, indicates that I do not want or authorize those specific records released. _____ Diagnosis, evaluation and/or treatment for alcohol and/or drug abuse.

      authorization to release medical certificate

    • [PDF File]AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

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      AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN THIS FORM I, _____hereby voluntarily authorize the disclosure of information from my health record. (Name of Patient) Patient Information: Patient Name: _____Record Number: _____ ...

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    • [DOCX File]AUTHORIZATION TO DISCLOSE MEDICAL RECORDS

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      Authorization for Release of Medical Records. This authorization is for the disclosure of health information pertaining to: Last Name: _____ First: _____ MI ___ DOB: _____ Phone Number: _____ I hereby authorize the disclosure of my health information to: Stanford University Medical Center. Cardiac Electrophysiology and Arrhythmia Service. c/o Dr. Marco Perez. 300 Pasteur …

      printable request for medical records

    • [DOC File]AUTHORIZATION TO RELEASE MEDICAL RECORDS

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      the spaces below, I specifically authorize the release of the following medical records, if such records exist: ____ Please send the . entire medical record (this includes any or all of the items listed below). ____ Medical records needed for continuity of care____ Gynecologic exams, Pap smears and associated lab results ____ Clinic office chart notes____ Contraception records …

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    • [DOC File]Authorization for Release of Medical Records

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      Authorization for Release of Confidential Medical Records. All sections of this authorization must be completed for the release of medical information. The release of records may be subject to a charge. Patient Name: Date of Birth: I hereby authorize: To release information to: *All records will be released unless specifically noted below.* Indicate the exact information to …

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    • [DOCX File]AUTHORIZATION FOR RELEASE OF MEDICAL RECORD …

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      I authorize the release of my health information for the following specific purpose: _____. (Note: “at the request of the patient” is sufficient if the patient is initiating this Authorization) Information to be disclosed: I authorize the release of the following health information: (check the applicable box below) All of my health information that the provider has in his or her possession ...

      release of medical information form

    • [DOC File]AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

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      My decision to revoke the authorization does not apply to any release of my records that may have taken place prior to the date of my revocation of the authorization. My decision to revoke the authorization my result in my insurance company not being able to pay for my medical care and I understand that I may be responsible for payment of the claim. Western Wake Surgical, …

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    • [DOC File]Authorization for the Release of Medical Records

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      NOTE: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-Petris-Short Act. 2. 05.11 Updates: 9/13/2018

      authorization to release medical information

    • [DOC File]AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

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      AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION. I authorize: and: to exchange information for the purpose of [ ] continued treatment, [ ] reimbursement for treatment, [ ]evidence of care, [ ] other. regarding: (Print patient's name)(Birthdate) The information to be released/exchanged includes: [ ] medical information only [ ] medical records only [ ] medical information and records ...

      authorization to release medical certificate

    • Free Medical Records Release Authorization Form | HIPAA - PDF | …

      I authorize the release of the following health information: (check the applicable box below) All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me. Including STI and substance abuse records.

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    • [DOC File]Authorization for Release of Confidential Medical Records

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      AUTHORIZATION TO RELEASE MEDICAL RECORDS. Date:_____ Full Name of Patient/s: _____ _____ _____ _____ _____ _____ Name of Person Requesting Records: Relationship to Patient/s: _____ _____ Reason For Request: _____ Standard Transfer Packet OR Specific Records Requested: Name and Address of person to forward medical records to: _____ _____ _____ I attest that I have a legal right to these medical

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    • [DOC File]AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

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      A general authorization for the release of medical or other information if held by another party is NOT sufficient for this purpose. Regulations state that any person who violates any provision of this law shall be fined not more than $500 in the case of the first offense and not more than $5,000 in the case of each subsequent offense. I consent to the re-disclosure of information …

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