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Patient Authorization for Release of Medical Information This form allows LSI LLC to send records on your behalf Laser Spine Institute LLC Medical Records Department 3031 N. Rocky Point Drive E. Tampa FL 33607 Phone 813-289-9613 Fax 813-597-2616 Patient Name Date of Birth Address City Phone Last 4 digit SS State Zip Email I hereby authorize Laser Spine Institute LLC its affiliates medical staff employees and their representatives to release my protected health information in the manner listed...
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How to fill out medical records release form

How to fill out a medical records release form:
01
Begin by obtaining a copy of the medical records release form from the healthcare provider or facility where your records are held.
02
Carefully read through the form to ensure that you understand all the information required and any specific instructions provided.
03
Fill in your personal information accurately, including your full name, date of birth, address, and contact details.
04
Provide the name and contact information of the healthcare provider or organization that you authorize to release your medical records.
05
Specify the purpose for which the medical records are being released, such as for personal records, legal proceedings, or for a new healthcare provider.
06
Indicate the timeframe for which the medical records release is valid, if applicable.
07
Sign and date the form, acknowledging your consent for the release of your medical records.
08
If required, have any additional parties involved, such as a legal guardian or power of attorney, sign the form as well.
09
Make copies of the completed form for your records and submit the original to the healthcare provider or facility.
Who needs a medical records release form:
01
Individuals who wish to transfer their medical records from one healthcare provider to another may need a medical records release form.
02
Patients who are enrolling in a new healthcare facility or starting treatment with a new healthcare provider may be required to complete a medical records release form.
03
In legal matters, attorneys may require their clients to sign a medical records release form to access relevant medical records for a case.
04
Insurance companies or government agencies may also require a medical records release form to verify or process claims.
05
Family members or individuals acting on behalf of a patient may need to submit a medical records release form in order to access their medical information.
Note: Specific requirements regarding the need for a medical records release form may vary depending on the jurisdiction and policies of the healthcare provider or organization involved.
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