Authorization Form for Medical Records Release

To submit this form, complete all required fields and sign where indicated. You can send the completed form via fax to the Fertility Centers of Illinois at [insert fax number] or email it to [insert email address]. Additionally, you may also deliver the form in person at [insert physical address]. It is essential to ensure the form is filled out accurately to avoid processing delays.

There are no specific important dates related to this form as it is meant for ongoing use whenever a patient needs to request their medical records.

The primary purpose of this form is to authorize the release of a patient's medical records from Fertility Centers of Illinois. It provides a legal basis for sharing sensitive information between parties, ensuring confidentiality and compliance with applicable laws. This form is vital for maintaining continuity in patient care and personal health management.

• 1. Patient's Printed Name: The full name of the patient requesting the records.
• 2. Patient's Date of Birth: The birth date of the patient.
• 3. Patient's MPI Number: The unique medical record number assigned to the patient.
• 4. Spouse's/Partner's Printed Name: The full name of the spouse or partner, if applicable.
• 5. Spouse's Date of Birth: The birth date of the spouse or partner.
• 6. Spouse's/Partner's MPI Number: The unique medical record number for the spouse or partner.
• 7. Records Requested: Details on what medical records are being requested.
• 8. Authorized Recipient Name: Name of the individual or entity authorized to receive the records.
• 9. Recipient's Address: Communication address of the authorized recipient.
• 10. Recipient's Phone Number: Contact number of the authorized recipient.
• 11. Recipient's Fax Number: Fax number for sending the records.
• 12. Reason for Release: The reason why the medical records are being requested.
• 13. Expiration Date of Request: The date until which the authorization remains valid.
• 14. Patient's Signature: Signature of the patient authorizing the release.
• 15. Date: The date when the form is signed.
• 16. Spouse's/Partner's Signature: Signature of the spouse or partner if applicable.
• 17. Person Processing Records: Name of the individual processing the record request.
• 18. Manager/MD Signature: Signature of the manager or MD reviewing the records.

Failing to submit this form may result in delays in obtaining essential medical records. Without this authorization, your healthcare providers may not release your confidential information. Consequently, your continued treatment and personal health management could be compromised.

• Delay in Care: A delay in accessing necessary medical information could disrupt ongoing treatment plans.
• Inadequate Documentation: Failure to obtain records may lead to incomplete personal healthcare documentation.
• Potential Miscommunication: Without the necessary information, communication between healthcare providers may suffer.
• Legal Implications: Lack of proper documentation could complicate legal matters regarding health decisions.
• Insurance Denials: Absent records may result in denial of insurance claims and benefits.

• 1. Transitioning to New Provider: When moving to a different healthcare provider, you'll need to ensure they have access to your prior medical records.
• 2. Insurance Claims Processing: In order to process claims efficiently, insurance companies often require access to specific medical records.
• 3. Legal Documentation: Legal representatives may need access to medical records for representation in health-related matters.
• 4. Personal Records Organization: Patients often keep copies of their medical history for personal documentation.
• 5. Research Purposes: Research organizations may request records for studies related to healthcare practices.