I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. §1320d et seq. (“HIPAA”) and the Health Information Technology for Economic and Clinical Health Act of 2009 (“HITECH”), I hereby authorize my providers to RELEASE and DISCLOSE my entire medical record, including but not limited to patient histories, office notes, test results, radiology studies, pathology slides, films, referrals, consults, billing records, insurance records, records sent to you by other healthcare providers, and any other protected health information for the purpose of clinical research/trial as authorized in this medical records release consistent with my right to access
Notwithstanding the statement above, I do NOT authorize the release of medical records containing any of the following checked items:
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. §1320d et seq. (“HIPAA”) and the Health Information Technology for Economic and Clinical Health Act of 2009 (“HITECH”), I hereby authorize my providers to RELEASE and DISCLOSE my entire medical record, including but not limited to patient histories, office notes, test results, radiology studies, pathology slides, films, referrals, consults, billing records, insurance records, records sent to you by other healthcare providers, and any other protected health information for the purpose of clinical research/trial as authorized in this medical records release consistent with my right to access
This authorization expires one (1) year from the date it has been signed.
Patient or Legal Guardian Signature (This signature has been captured electronically):
To sign this form electronically: Using your mouse, hover in the shaded box area and a pen will appear. Click and hold down on the right mouse button to sign your name.
If you are using an IPad or cell phone, please use your finger to sign your name in the shaded box area.
A valid signature is required. Submitting this form without a valid signature may delay the patient authorization process. Please ensure that your signature remains within the signature box. Failure to do so may result in invalid signatures when submitted.
Date Signed:
If Legal Guardian, please describe authority to sign:
| |
FOR SUPPORT CALL: 877-344-8999, OPTION 1 |