CHJ-121 Medical Release Form. ASC X12/005010X214E2 Health Care Claim Acknoledgment (277CA) - michigan 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's full name, number, and date of birth in the designated fields at the top of the form.
3. Fill in the information regarding where the health records will be released from, including the facility name and address.
4. Next, specify where the information is being sent by providing the recipient's address.
5. Indicate specific dates for which information is to be released by filling in both beginning and ending dates.
6. Select the type of information you wish to release by checking appropriate boxes such as Medical, Dental, Mental Health, or Complete Health Record.
7. State the purpose of this release clearly in the provided section.
8. Finally, sign and date the form at the bottom to authorize disclosure. Ensure a witness also signs if required.

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