Authorization to Obtain Medical Records & Billing Information Form

Authorization to Obtain Medical Records & Billing Information is required if you are wanting to obtain any protected health information or PHI such as medical records or immunization records.

Here’s a step by step tutorial how to fill an Authorization to Obtain Medical Records & Billing Information  :

  • Enter in the patient’s name, date of birth, and social security number, and that would be for whoever’s records you actually needing. So, if it’s your own records and you put your name, date of birth, and social if it’s the information for your child, then you would put the child’s name, date of birth, and social there.
  • In the hereby authorized section, you’re going to list storage plus, and then in the to release the following information to section. And then in the to release the following information to section to receive the records, so, that’s yourself. Then you would want to put your name and your address right here. And then if it is for a doctor’s office or a school or military, then you want to put the person that’s receiving it and the organization name. It is worth noting though that the name and address of the person that you’re listing does need to match whatever is on their driver’s license or whatever government-issued photo ID that they’re going to use to pick up the records because it has to match. 
  • So, after that then you’re just going to go down to the second section here, where it says information to be shared, and that’s where you’re going to select what it is you’re needing. So, if you’re wanting an entire medical record and you just click the box or if you’re wanting just shot records for instance, and you would click other and you would just type in immunization records. Then you’ll go down to the information that may be disclosed for the following purposes. And typically speaking, most people are just going to select that it’s at their request. But if you have a different reason such as like the school is needing it or a daycare or something like that, that you could just put that in the other section.
  • After that then you’re going to want to read over these terms and conditions on the form to make sure that you understand what you’re authorizing and once you’ve done that, then you can go down to the bottom here. And then you’re just going to sign and date it. The date is just the day that you’re actually signing the form. You don’t need to put it in any kind of advance and then you would just put your name and then or the legal representative and if it is a legal representative, then you’re going to list with their authority. So if you’re a caregiver that you would list something like that in that field.
  • Basically, You would just have all of that information in there and then they’ll need to get that as well as a copy of the photo ID before they can release the records to you. Once they’ve received that back then they can determine if we actually have any records in storage that you’re looking for, at any cost that might be associated with obtaining those records. And it is worth noting also that if you have multiple people that you were looking to get information from, then you would want a separate form for each person. So if you had multiple children that you’re trying to obtain shot records for instance, then you would list a separate one for each child and then they would need all of that back and then we can get you the information you’re requesting.

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