Authorization for Release of Medical Information
This form allows patients to authorize Lenoir Memorial Hospital to release their medical information to designated individuals or organizations. It details the types of information that can be released and the importance of understanding the implications. Patients can specify their needs and ensure their medical records are shared securely.
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How do I fill this out?
To fill out this form, start by entering your personal details such as name, date of birth, and social security number. Next, specify who the information should be released to and the reasons for the release. Finally, indicate which medical records you wish to authorize for release by initialing the relevant sections.
How to fill out the Authorization for Release of Medical Information?
1
Enter your personal details accurately.
2
Specify the recipient of your medical information.
3
Indicate the reason for the release of information.
4
Initial the documents you wish to release.
5
Sign and date the form.
Who needs the Authorization for Release of Medical Information?
1
Patients needing copies of their medical records for personal use.
2
Attorneys requiring medical records for legal cases.
3
Insurance companies requesting medical information for claims.
4
Doctors referring patients requiring prior medical history.
5
Family members acting on behalf of the patient for healthcare decisions.
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What are the instructions for submitting this form?
To submit this form, please complete all the necessary fields and ensure your signature is included. You can fax the completed form to 252-522-7225 or send it via email to healthinfo@lenoirmemorial.org. Alternatively, you can mail a physical copy to 100 Airport Road, P.O. Box 1678, Kinston, North Carolina 28503-1678. It’s recommended to keep a copy for your records as well.
What are the important dates for this form in 2024 and 2025?
The authorization will remain valid for 90 days from the date of signing. After this period, a new authorization will be required for any further access to your medical records. It’s crucial to allow ample time for processing your requests.
What is the purpose of this form?
This form serves to authorize the release of a patient's medical information to designated individuals or entities. It is essential for maintaining the flow of necessary health information between patients and healthcare providers. This ensures that patients can manage their healthcare efficiently and securely, enabling better decision-making based on their medical history.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient authorizing the release.
- 2. DOB: The patient's date of birth for identification.
- 3. SSN: The patient's social security number for verification.
- 4. Release Information To: The individual or organization authorized to receive information.
- 5. Reason for Release: The purpose for which the medical information is requested.
- 6. Documents to Release: Specific medical records the patient wishes to authorize for release.
- 7. Signature: Signature of the patient or authorized representative.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in accessing necessary medical information. Without this authorization, healthcare providers cannot share your information with requested parties. It is crucial to complete and submit the form accurately to avoid disruptions in your care.
- Delayed Treatment: Without the necessary information, your treatment may be delayed.
- Legal Ramifications: Not submitting may affect legal proceedings related to healthcare.
- Incomplete Medical History: Inadequate information can lead to misunderstandings about your health.
How do I know when to use this form?
- 1. Insurance Claims: Use when your insurance requires medical records for claim processing.
- 2. Legal Matters: Necessary for attorneys needing healthcare information for legal cases.
- 3. Personal Health Management: Helps patients share their medical history with new healthcare providers.
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