Medicaid Medical Record Documentation Resource Handout 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Account Number' and 'Date ROI Received' at the top of the form. Ensure these fields are completed accurately for proper tracking.
3. In the 'Authorization for Release of Protected Health Information (PHI)' section, clearly print the patient's full legal name, date of birth, street address, social security number, city, state zip code, phone number, and email address.
4. Indicate whether a message can be left at the provided phone number by checking 'Yes' or 'No'.
5. Fill out the 'Release Information From' and 'Release Information To' sections with the appropriate names and addresses.
6. Select the purpose of release by checking one of the options provided. Specify dates of treatment to be released.
7. Check all applicable information to be released under 'INFORMATION TO BE RELEASED'.
8. Choose your preferred method of delivery for receiving documents.
9. Review patient rights carefully before signing. Ensure you understand all terms outlined in this section.
10. Finally, print your name, sign where indicated, and date your signature. If applicable, have an authorized representative sign and check their relationship/authority.

Start using our platform today to fill out your Medicaid Medical Record Documentation Resource Handout easily and for free!