HCP Records Request

Company Name *

Name *

First Name Last Name

Email

example@example.com

Phone Number *

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Patient Name *

First Name Last Name

Ambulance Provider *

You are submitting a request for Medical and/or Billing records on the above referenced patient. It is the policy of HEALTH CLAIMS PLUS to receive a processing fee, this form, and a patient/guardian authorization prior to record release. If requested records are regarding a deceased patient, additional documents such as a will or other pertinent document(s) to support the requesting/authorizing party's position as executor may be required.

Select applicable records type & fee

Make CHECK payable to: HEALTH CLAIMS PLUS

Mail to: 2800 Beaumont Ave., Ste. E

Liberty, TX 77575

*we currently are not accepting credit card payment for medical records.

Tax ID: 76-0639594

*AUTHORIZATION & CONFIDENTIALITY NOTICE*

Authorization to Release Records - By submitting a medical/billing authorization & request for records, it is understood that the requesting party is authorized to receive such records. It is understood that HCP charges for requested copies to cover the costs incurred in searching, handling, copying, and mailing documents/records. All fees are to be paid in advance, before the release of any records. Check payable to Health Claims Plus to the address above. Documents/Records will be received 7-14 days from our receipt. Attorneys should submit proof of representation with each request to include photo ID with signature of patient named in request. CONFIDENTIALITY NOTICE - This document may contain information covered under the Privacy Act, 5 USC 552(a), and/or the Health Insurance Portability and Accountability Act (PL104-191) and its various implementing regulations and must be protected in accordance with those provisions. Healthcare information is personal and sensitive and must be treated accordingly. If this correspondence contains healthcare information, it is being provided to you after appropriate authorization from the patient or under circumstances that don't require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-discloser without additional patient consent or as permitted by law is prohibited. Unauthorized re- disclosure or failure to maintain confidentiality subjects you to application of appropriate sanction. Additionally, this electronic message and all contents and attachments contain proprietary information from Health Claims Plus, which may be privileged, confidential or otherwise protected from disclosure.The information is intended to be for the sole use of Health Claims Plus business and activities. Any disclosure, copy, disclosure. distribution or use of the message, or its contents or any of its attachments, is prohibited.

I acknowledge and understand that I must complete & print this form, mail it along with applicable payment, patient authorization form(s), provide any applicable affidavits or direct questions [wholly "Records Packet"]. I understand that any incomplete records packets received by Health Claims Plus are subject to immediate destruction/shredding without further notification.

Request for Records