ROI - Medical Record Request

Medical Record Request

Release of information (ROI)
I am*

The PatientParent / Guardian / Legal representative / Authorized 3rd party / Other
I am requesting*

Medical Records RequestForms or Paperwork completion request e.g. FMLA, Disability or other formsGenetic Testing Request

Please select the option that best describes your request:*

I want to share or release my LunaJoy records to 3rd partyI want to give LunaJoy permission to obtain my medical records from 3rd party

parent/guardian/legal representative/authorized 3rd party/other
Parent/guardian/legal representative/authorized 3rd party/other Details
Enter your name/entity*
Entity Tel #*
Email*
Which best describes their relationship to the patient*

Parent with Parental RightsCourt Appointed GuardianLegally Appointed Health Care AgentPower of Attorney with Right to See Medical RecordsCourt Appointed Personal Representative of DeceasedOther
Please upload documentation of your legal authority for this request and relationship with the patient. Please note, requests submitted without appropriate documentation will be closed*

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Patient Details
Patient Details
Patient Name*
Birth Date*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Email

Request records to
Name of Person/Entity *
The party to whom records will be requested:*

Doctor's Office / Hospital / Medical Clinic / Other 3rd Party
Person/Entity Tel#:*
Please enter a valid phone number.
Person/Entity Fax#*
(all medical records will be faxed to this number)

Genetic Test Request

Please fill out the form allowing us to share your information with Gene Sight. In the name section, please put " GenoMind- www.genomind.com, phone number: 877-895-8658." You can then checkmark what we are allowed to share with the company.
Name of Person/Entity LunaJoy is releasing/requesting information to:*
Person/Entity Tel#:*
Please enter a valid phone number.

Release To:

Release To Section
Name of Person/Entity LunaJoy is releasing/requesting information:*
The party to whom records will be released/shared is:*

Doctor's Office / Hospital / Medical ClinicOther Third Party / Company
Person/Entity Tel#:*
Please enter a valid phone number.
Person/Entity Fax#
(all medical records will be faxed to this number)

MR SECTION ONLY
I understand that all record requests will be sent via Fax to the phone number above*

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I understand that records and information may include information about Substance Abuse and/or Alcohol Abuse, HIV/AIDS, or STDs, and Mental Health Records.*

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I understand there may be a fee for this release. I understand that all fees will be in compliance with applicable law. I agree to pay this fee. Medical records cannot be released until fees have been settled.*

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I understand that all medical, surgical, psychiatric, and psychological information is confidential and that patient records are the property of LunaJoy Health Inc. and its related corporate entities. I will not hold LunaJoy, its employees, staff, or representatives responsible for any damage, mental or physical, which may be caused by the release of patient records and the information contained therein.*

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I understand that my authorization for release may be revoked at any time by written request to LunaJoy at (care@hellolunajoy.com), but may not be revoked to include the release allowed by this document. Also, if this authorization is permission for LunaJoy to disclose information to an insurance company, in order for me to obtain insurance coverage, the insurance company may still have the legal right to use the information to contest my coverage.*

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I understand that the person or organization that receives the information because of this authorization may disclose this information to other people or organizations without my knowledge or consent. Therefore, I hereby release LunaJoy, its employees, staff, and representatives from all liability relating to or arising out of this release of information contained in LunaJoy patient records.*

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I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign and will not base my treatment or payment whether or not I provide authorization for the requested use or disclosure. I understand that I may inspect or copy the information to be disclosed as provided in CFR164.524 (with reasonable charge).*

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This authorization shall expire when the client is discharged from the current episode of care (treatment has been completed, the client rejects/declines/drops out of treatment, is referred elsewhere, moves, or in the case of the client's death.) This agreement is subject to revocation in writing at any time.*

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If you are NOT the patient but are signing on behalf of the patient, please attach proof of your authority to act on behalf of the patient. If proof of authority is not attached, the request will be terminated.
File Upload*

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Print your name*
Which best describes your relationship to the patient*

PatientParent with Parental RightsCourt Appointed GuardianLegally Appointed Health Care AgentPower of Attorney with Right to See Medical RecordsCourt Appointed Personal Representative of DeceasedOther
Signature*

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Date*

MonthDayYear
Email Address*
example@example.com
Phone Number*

Submit Button Section

My Products*

Medical Record and Paperwork RequestLunaJoy has determined there is a $75 charge for your request. By continuing with this transaction, you are authorizing LunaJoy to charge the card entered below. By clicking "continue" or proceeding with the transaction, you acknowledge and agree to this authorization.

$75.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Medical Record Request

Parent/guardian/legal representative/authorized 3rd party/other Details

Patient Details

Request records to

Genetic Test Request

Release To:

Medical Records Request

Forms or Document Completion Request