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How do I fill this out?
To fill out this form, provide your personal information in the 'Patient Information' section and specify what medical records you wish to request.
How to fill out the Northwestern Medicine Medical Information Release?
1
Fill in your personal and contact information.
2
Select the medical records to be released.
3
Specify the purpose for the information release.
4
Choose the delivery method for the released information.
5
Sign and date the form before submission.
Who needs the Northwestern Medicine Medical Information Release?
1
Patients needing copies of their medical records.
2
Attorneys requiring access for legal cases.
3
Insurance companies to process claims.
4
Healthcare providers for continued care.
5
Research organizations needing medical data.
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What are the instructions for submitting this form?
Submit to Health Info Management at 25 North Winfield Road, Winfield, IL 60190, or fax to 312.926.3093 or email to releaseofinformation@nm.org.
What are the important dates for this form in 2024 and 2025?
The form is valid for six months upon signing, with recommended submission 30 days before needed access.
What is the purpose of this form?
To authorize release of medical records, ensuring continuity of care and legal compliance.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Personal and contact details.
- 2. Release Information From: Source of medical information.
- 3. Purpose of Release: Reason for record request.
- 4. Medical Records Requested: Types of records to receive.
- 5. Delivery Method: How records will be sent.
What happens if I fail to submit this form?
Failure to submit may prevent obtaining necessary records.
- Delay in Care: Not having records can delay treatment.
- Legal Complications: May hinder legal proceedings.
- Insurance Claims Issues: Could affect claim processing.
How do I know when to use this form?
- 1. Transferring Care: Facilitates sharing medical history.
- 2. Legal Representation: Attorneys may require records.
- 3. Insurance Processing: Needed for claims.
Frequently Asked Questions
What is the purpose of this form?
To authorize the release of medical information.
How can I edit this PDF?
By uploading it to PrintFriendly.
Can I sign this PDF using PrintFriendly?
Yes, you can add your signature easily.
How do I submit the completed form?
Via mail, fax, or email.
What types of records can I request?
Hospital stays, outpatient records, and test results.
How long does it take to process?
Up to 30 days.
Is there a fee for records?
Standard copying fees may apply.
Can I revoke my authorization?
Yes, by withdrawing in writing.
Who can I contact for questions?
The Health Information Management Department.
What happens if I do not submit?
You may not obtain necessary records.
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