Release of Records Request
Patient Information
Name
First Name
Last Name
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Record Request Information
Please choose from the following options:
I am requesting information for the following dates: (you may go back three (3) years) (MM/DD/YYYY) - (MM/DD/YYYY)
Which year(s) would you like to receive your detailed Medication Expense Report for?
Please describe the information you wish to access.
I would like the following people to have access to my medication records. Please list their names:
I am allowing them access to the following record(s) (please list your preferences):
*If the records are being requested for a spouse or child that is above the Age of Medical Consent, they will bemailed directly to the patient. **Typical records request are completed in less than one (1) business day, but extra time may be required if recordsare requested during holidays, weekends, or peak business hours. In rare circumstanaces, please understand thatsome record requests may be delayed up to seven (7) days if the requested information is stored off-site.
Signature*
We are required to recieve a form and signature from each individual requesting records prior to processing each request.
(Please use Mouse or Finger to sign below)
Submit
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