Medical Records Request Form
By signing this form, I am authorizing the selected entities/individuals to receive confidential HIPAA protected medical records from HWS Best Health, LLC (1303 W. Maple St. Ste. 102 North Canton, OH 44720).
Client's Name
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First Name
Last Name
Client's Date of Birth
*
-
Month
-
Day
Year
Date
Client's Social Security Number
Please provide when possible
Name of Individual/Organization to Receive Medical Records
*
Method of Disclosure:
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Printed - Pickup in person (Fee)
Printed - Mailed (Fee + Cost of Postage)
Fax (If chosen, provide a valid fax # above)
Email (If chosen, provide a valid email address above)
Reason for Disclosure:
*
Continuity of Care
Transfer of Care
Disability
Insurance Application
Legal
Insurance Payment/Claim
Personal Use or Review
Other
If this request is to send records to another health care provider, is this a termination of provider-patient relationship with your HWS Best Health provider(s), and a formal transfer of your care to another health provider who is not in HWS Best Health?
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Yes
No
Configurable list
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What information should be shared? Check all that apply:
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All record types in this list may be disclosed on behalf of the above named individual.
Identifying information: name, birth date, social security number, sex, race, address, email address and telephone number.
Mental Health Assessment/Psychosocial Assessment/Diagnostic Assessment/ Integrated Assessment.
Psychiatric Evaluation/H&P/lnpatient Psychiatric Record.
Psychological Evaluations including Forensic/Court Psychological, Neuropsychological, School Psychological or others.
Discharge reports and summaries
Progress Notes/Progress Reports
Diagnosis Lists
Medication Lists
General Medical: medical records (except for HIV, AIDS and drug and alcohol treatment records) disability, type of services being received and name of agency providing services to me or the individual named above.
Social History: social history, treatment/service history, psychological evaluations and other personal information regarding the individual named above or me.
School Information: grades, attendance records, Individualized Education Plan (IEP), Individualized Family Service Plan (IFSP), 'Individualized Service Plan (ISP), Multi-Factored Evaluation (MFE), (Children's) Ohio Eligibility Determination Instrument (COEDI/OEDI), transition plans and vocational assessments regarding me or the individual named above.
Financial Information necessary to establish eligibility for public assistance including but not limited to pay stubs, W2's and tax returns, and other financial information.
Other
Information of the Individual Completing this Release of Information
*
Did an HWS staff member/employee/provider assist you with completing this form?
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Yes
No
HWS Provider/Staff Member Assisting
*
First Name
Last Name
HWS Provider/Staff Member Email Address
*
example@hwsbesthealth.com
Reason for Providing Assistance
*
Sign Here Using Your Mouse
*
Submit
Submit
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