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How do I fill this out?
To fill out this form, provide the required information about the owner and patient, specify the records to be disclosed, and indicate the purpose of disclosure. Then, sign and date the form as required.
How to fill out the Authorization to Release Medical Records?
1
Provide owner and patient information.
2
Specify the records to be disclosed.
3
Indicate the purpose of disclosure.
4
Sign and date the form.
5
Submit the form via the provided methods.
Who needs the Authorization to Release Medical Records?
1
Pet owners needing to transfer their pet's care to another facility.
2
Veterinarians requiring access to a patient's medical history.
3
Legal professionals needing medical records for a case.
4
Insurance companies verifying treatment and billing details.
5
Researchers conducting studies involving animal medical histories.
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What are the instructions for submitting this form?
Please return the signed and completed form via fax to (607) 253-3293, email to vet-medrec@cornell.edu, or mail to Cornell University Hospital for Animals, Medical Records VMC Box 35, Ithaca, NY 14853. Ensure all fields are completed accurately to avoid any delays. Contact the Medical Records department if you have any questions or need further assistance.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this form in 2024 and 2025. The form's expiration date is determined by the user when filling out the form.
What is the purpose of this form?
The purpose of this form is to authorize the release or obtainment of medical records for a patient at Cornell University Hospital for Animals. It is essential for ensuring continuity of care, legal documentation, insurance claims, and other purposes. By filling out this form, the pet owner provides consent for their pet's medical information to be shared or received as needed.
Tell me about this form and its components and fields line-by-line.
- 1. Owner Name: The name of the pet's owner.
- 2. Patient Name: The name of the pet patient.
- 3. Species: The species of the pet (e.g., dog, cat).
- 4. Case #: The case number assigned by the hospital.
- 5. Address: The owner's address.
- 6. City: The owner's city.
- 7. State: The owner's state.
- 8. ZIP: The owner's ZIP code.
- 9. Authorized Recipient Information: Information about the party authorized to receive the medical records, including name, address, and contact details.
- 10. Description of Information Disclosed: Details of the medical information that may be disclosed, including types of records and dates of service.
- 11. Purpose of Disclosure: The purpose for which the information will be used or disclosed.
- 12. Owner Signature: The owner's signature authorizing the release or obtainment of medical records.
- 13. Date: The date the form is signed.
What happens if I fail to submit this form?
Failure to submit this form may lead to delays in transferring medical records and providing continuity of care for the pet.
- Delay in Medical Treatment: Without the necessary records, there may be delays in diagnosing and treating the pet.
- Legal Issues: Legal issues might arise if medical records are not available for cases involving the pet.
How do I know when to use this form?
- 1. Transferring Care: When the pet is transferring to a new veterinary facility.
- 2. Legal Purposes: For legal matters requiring access to the pet's medical history.
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