Affidavit and Authorization for Release of Information
This affidavit is a request form for the release of information from the Federation of State Medical Boards. It is essential for those needing to verify credentials or obtain records related to their medical history. Proper completion ensures a smooth processing of your request.
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How do I fill this out?
To fill out this form, start by entering your personal details in the designated fields. Ensure that all information is accurate and matches the identification documents. Once completed, review and sign the affidavit to authorize the release of your information.
How to fill out the Affidavit and Authorization for Release of Information?
1
Enter your full name and contact information.
2
Provide the physician's printed name and signature.
3
Include the date of signature.
4
Review all provided information for accuracy.
5
Submit the form via email or fax.
Who needs the Affidavit and Authorization for Release of Information?
1
Medical professionals who require verification of credentials.
2
Patients requesting their medical records for personal use.
3
Educational institutions needing student records for admissions.
4
Employers conducting background checks on potential hires.
5
Credentialing agencies verifying the status of healthcare practitioners.
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Review all changes to ensure accuracy.
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What are the instructions for submitting this form?
To submit this form, you can send it via email to closedprograms@fsmb.org or fax it to 817-868-4150. Additionally, you can mail the completed form to the Federation of State Medical Boards, Attn: Student Records, 400 Fuller Wiser Road, Euless, TX 76039. Always ensure that you verify the correct destination for your submissions.
What are the important dates for this form in 2024 and 2025?
Important dates for using this form typically align with the application or verification processes of medical boards. Check relevant education and employment deadlines for timely submission. Always refer to official schedules for the most accurate information.
What is the purpose of this form?
The purpose of this affidavit is to authorize the release of personal information from medical boards. It serves as a legal declaration that the undersigned is the rightful individual requiring this information. By signing this form, individuals ensure that their records can be accessed by proper entities, facilitating verification processes.
Tell me about this form and its components and fields line-by-line.
- 1. Physician's Printed Name: The full name of the physician authorized to release information.
- 2. Physician's Signature: The signature of the physician affirming the request.
- 3. Date of Signature: The date when the affidavit is signed.
- 4. Physician's Telephone Number or Email Address: Contact information for the physician.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in processing requests for medical information. It is essential for the involved parties to have accurate and timely access to pertinent data. Not completing this form can hinder credential verifications requiring confirmation.
- Delay in Process: Your request may take longer to process without this form.
- Inaccurate Records: Incomplete information may lead to errors in your records.
- Denial of Requests: Without proper authorization, requests for information can be denied.
How do I know when to use this form?
- 1. Medical Employment Verification: Needed for potential employment in healthcare settings.
- 2. Student Admissions: Required for educational institutions during enrollment.
- 3. Credentialing by Boards: Utilized for credential confirmation by medical boards.
Frequently Asked Question
How do I fill out the affidavit?
Begin by providing your personal information and ensure it matches your identification.
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After completing the form, remember to review it before submitting.
How can I submit this form?
You can submit the form via the provided email or fax number.
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