Your provider’s medical request release form may be organized differently — there is not a standard form — but these are the questions you’re likely to see.

Patient information

Whose health records do you want? Print their full name, date of birth, patient identification number (PIN), or medical record number (MRN). (PINs and MRNs are assigned by providers. If you don’t know your number, you can ask your provider.) Only 1 person per form.

Clinic, hospital, care provider

Who has the information you want? This can be a name of any health care provider or facility that has the records to be released. Include full name, address, phone number, and secure fax or secure email address.

Date of Services

Who has the information you want? This can be a name of any health care provider or facility that has the records to be released. Include full name, address, phone number, and secure fax or secure email address.

Information to be released

What information do you need? This is to guide your provider in pulling the records you need. Often, it will be a set of check boxes. Check all that apply.

Receiving party or destination of records

Where do you want to send the information? Enter the complete name of person, physician, facility, or company, along with their address, telephone number, and fax number or secure email (through their patient portal). Note: If you need to send your records to more than 1 person or facility, including yourself, a separate request may be required. Ask your provider what they need.

Purpose of release

Why do you need this information? Often, the form will offer a set of check boxes, like ongoing care or new doctor. You can check all that apply, but according to HIPAA, you don’t have to provide this information in order to get your health record. So you can leave this section blank.

Expiration date or duration of consent

How long do you want this release to be valid? Not all forms will include this section. However, if you don’t specify a date, most releases expire 6 months to 1 year from the date you filled out the release. Note: According to HIPAA, you don’t have to provide this information in order to get your health record, and you can leave this section blank.

Release instructions

How and when do you want to have this information? This tells your provider if you’d like your records by a certain date and in a certain format. Although you may be able to specify a shorter time frame, your provider can take up to 30 days to deliver your health record. 

Signature of Patient or Personal Representative (also called “Patient Representative”)

You must sign the form, or your provider will not be able to process your request.

Date

Enter the date for the day you sign the authorization form.

Relationship to Patient

If you’re not the patient, how are you related to the patient? This will tell the provider if you are the parent of a child or a personal representative.

Legal Authority

If you’re requesting health records for someone other than your child, you may be required to provide a copy of the legal paperwork giving you the right to access their health information — if their health care provider does not already have it.

Questions
If you have any questions or concerns please contact us via the "help button" in the bottom right hand corner of the screen or email us at at support@onerecord.com.

Source: HealthIT.gov

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