Medical Records Release Format - Fairfield Memorial Hospital - fairfieldmemorial 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and contact information, including daytime and cell phone numbers, as well as the date of birth.
3. In the 'Information to be released' section, check all applicable boxes for the types of medical records you wish to obtain, such as discharge summaries, lab results, and physician notes.
4. Specify the treatment dates for which you are requesting records by filling in the 'from' and 'to' fields.
5. Indicate the purpose of the information disclosure by checking relevant boxes like 'Continuation of Care' or 'Insurance'.
6. Fill in the details for both 'Release TO' and 'Release FROM', including names, addresses, and contact information.
7. If applicable, initial next to any sensitive information that you authorize for release.
8. Finally, sign and date the form at the bottom before submitting it through our platform.

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