How to write a Patient Medical Records Release Form? Download this Patient Medical Records Release Form template that will perfectly suit your needs.
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Release by: Release to: Facility Organization, Agency, Individual Address Attn: City, State, Zip Code Address HIM Phone/Fax Numbers City, State, Zip Code Treatment Date(s): Type of Disclosure Authorized Delivery Instructions: Purpose: Further Medical Care Workers’ Comp Provide copies of records to organization/agency/individual Personal Use Insurance Legal Mail records directly to address above Marketing/Fundraising Call to pick-up records: Other: Fax records to: Pertinent Protected Health Information Allowed to be Included: Discharge Summary Radiology Special Studies Entire Medical Record History Physical/Consult Outpt Record Medication Records Operative Report Progress Notes Psych Health Records Labs Physician Orders Other (specify): Psychotherapy Notes are distinct and may not be included with the disclosure of any other protected health information..
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