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John F Zwetchkenbaum MD - Asthma & Allergy Physicians Of

John F Zwetchkenbaum MD - Asthma & Allergy Physicians Of 2025

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The document is a Medical Record Release Form from Asthma & Allergy Physicians of RI, Inc., authorizing the release of a patient's medical information to a specified recipient. It includes sections for patient details, the purpose of the request, and types of records requested. The form outlines the patient's rights regarding consent and revocation, as well as associated fees for record release.

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Click ‘Get Form’ to open the Medical Record Release Form in the editor.
Begin by entering the Patient Name and Date of Birth in the designated fields. This information is crucial for identifying the correct medical records.
In the section labeled 'I hereby authorize AAPRI to release medical information to:', fill in the Name, Telephone, Address, and Relationship to Patient. Ensure accuracy as this will determine where the records are sent.
Select the Medical Information Requested by checking the appropriate boxes. Options include 'All Records', '2nd Opinion', or specific records from a date range.
Provide a Reason for request by selecting from options like 'Moving' or 'Insurance has requested'. If none apply, use 'Other' and specify.
Finally, sign and date at the bottom of the form. This signature authorizes the release of your medical records as per your selections.

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2019	4.8 Satisfied (132 Votes)

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