Licking Memorial Health Systems Medical Record Request
This file is a request form for releasing medical information from Licking Memorial Health Systems. It is essential for patients seeking to obtain their medical records or share them with third parties. Proper completion of this form ensures a smooth process in accessing your health information.
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How do I fill this out?
To fill out this form, carefully read each section. Begin by providing your personal details in the designated fields. Follow the instructions on checking the required boxes for record release and purpose of disclosure.
How to fill out the Licking Memorial Health Systems Medical Record Request?
1
Provide your personal details and contact information.
2
Specify the records you want released and the purpose of the request.
3
Choose the format you would like to receive the records in.
4
Sign and date the authorization to release your medical information.
5
Submit the completed form as instructed.
Who needs the Licking Memorial Health Systems Medical Record Request?
1
Patients who want to access their medical records.
2
Healthcare providers requesting records for treatment purposes.
3
Attorneys needing medical records for legal cases.
4
Insurance companies requiring medical information for claims.
5
Family members seeking medical information on behalf of a patient.
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Use editing tools to fill out the necessary sections.
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Make any additional modifications as needed.
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Save your edited document.
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Download or share the PDF as required.
What are the instructions for submitting this form?
To submit this form, please send it via fax to 220-564-4132 or email it to medicalrecords@lmhs.com. You may also choose to submit it physically by mailing it to 2200 Markey Rd, Newark, OH 43055. Ensure all details are accurate to avoid delays in processing your request.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this form, but it's essential to submit it as soon as you require access to your medical records in 2024 and 2025 to avoid delays.
What is the purpose of this form?
The purpose of this form is to authorize Licking Memorial Health Systems to release your medical information to designated individuals or organizations. Patients often need to provide this authorization for continuity of care, legal requirements, or insurance processes. By filling out this form, you ensure that your medical records can be shared in a timely and efficient manner.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient as it appears in the records.
- 2. Date of Birth: The patient's birthdate to verify identity.
- 3. Social Security Number: The social security number for additional verification if required.
- 4. Medical Record Number: The unique identifier associated with the patient's medical record.
- 5. Contact Information: Places for phone numbers and addresses for communication purposes.
What happens if I fail to submit this form?
If this form is not submitted correctly, your request for medical records may be delayed or denied. It is crucial to ensure all fields are filled out accurately to avoid complications.
- Incomplete Information: Failure to provide necessary personal details can result in rejection.
- Missing Signatures: Not signing the authorization form may invalidate the request.
- Incorrect Dates: Specifying incorrect or incomplete dates of service can lead to difficulties in processing.
How do I know when to use this form?
- 1. Transitioning Doctors: Patients changing healthcare providers will need this form to share their records.
- 2. Legal Matters: Attorneys may require this form to gather medical evidence for cases.
- 3. Insurance Claims: Insurance companies often request this form to process claims effectively.
Frequently Asked Questions
What is the purpose of this medical record request?
The purpose of this request is to authorize the release of your medical information from Licking Memorial Health Systems.
How do I fill out the form correctly?
Carefully read each section and fill in your details, specifying what records you need and for what purpose.
Can I edit this PDF on PrintFriendly?
Yes, PrintFriendly allows you to edit your PDF directly for your convenience.
How do I submit this request?
You can submit this form by following the provided instructions for fax, email, or physical submission.
What if I need to revoke my authorization?
You can revoke your authorization at any time as long as you haven’t disclosed the information already.
How can I share my completed form?
Once edited, you can share the form via email or other sharing functionalities built into PrintFriendly.
Is there a fee for obtaining my medical records?
There may be charges associated with copying and releasing your medical information.
What information is included in my medical records?
Your medical records may include your history, treatments, labs, and any other relevant health information.
How long does it take to receive my records?
The processing time may vary, but it’s advisable to check with the medical records department.
What if I have additional questions?
For further inquiries, please contact Licking Memorial Health Systems directly.
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