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Release medical records form - Passaic Pediatrics

Release medical records form - Passaic Pediatrics 2025

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The document is a medical records release form from Passaic Pediatrics P.A., allowing a parent or legal guardian to authorize the release of their child's medical records to specified doctors. It includes sections for patient names and dates of birth, as well as a confidentiality notice regarding the handling of sensitive information.

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Click ‘Get Form’ to open the Release medical records form in the editor.
Begin by entering the date at the top of the form. This is essential for record-keeping purposes.
In the section labeled 'To:', fill in the name and address of the individual or entity receiving the medical records.
Next, list each patient's name along with their date of birth in the provided fields. Ensure accuracy to avoid any issues with record retrieval.
Select which physician(s) you wish to release your child's medical records to by checking the appropriate boxes next to their names.
Finally, provide your name as the parent or legal guardian and sign where indicated. This signature authorizes the release of information.

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Versions	Form popularity	Fillable & printable
2015	4.5 Satisfied (33 Votes)
2012	4.5 Satisfied (44 Votes)

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How do I write a letter of request for medical records?

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses notes; test results; consultations with specialists; referrals).]

How do you write a letter to release?

Templates Of Request For Relieving Letter [Date]Subject: Request for Relieving LetterI am [your name] and my employee ID is [your employee ID number]. I resigned from [name of the company], from my position as [your designation] in the [your department], on [date of resignation].

How do you write an authorization letter for medical records release?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

How do you write a letter to release medical records?

Releasing Your Medical Records Format your letter. You can set up your letter like a standard business letter. Draft the authorization. State the time period for disclosures. Identify what information to release. Identify how long your authorization is effective. Include other general provisions. Sign the release.

How do I write a HIPAA release letter?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.