Medical Records Request Form

Medical Records Request Form
Client's Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Client's Social Security Number
Please provide when possible
By signing this form, I am authorizing the selected entity(ies)/individual(s) to receive confidential HIPAA protected medical records from HWS Best Health, LLC (1303 W. Maple St. Ste. 102 North Canton, OH 44720).
Name of Individual/Organization to Receive Medical Records*
Method of Disclosure:*

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 CareTransfer of CareDisabilityInsurance ApplicationLegalInsurance Payment/ClaimPersonal Use or ReviewOther
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?*

YesNo
Date Range of Records Requested - Records will only be provided for the range you input here.*
What information should be shared? Check all that apply:*

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 summariesProgress Notes/Progress ReportsDiagnosis ListsMedication ListsGeneral 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
The purpose of the exchange of information authorized above is to improve communication between these entities/individuals so that I may receive the most coordinated, appropriate, and safest services while minimizing unnecessary involvement with the legal system. I understand that my alcohol and/or drug treatment records receive special protection under federal law 42 CFR Part 2 and can only be redisclosed as permitted by federal regulations. I understand that my physical and mental health treatment records are protected by HIPAA but may be subject to redisclosure if the recipient of my information is not subject to HIPAA.

HWS Best Health, LLC will not condition treatment, payment, enrollment, or eligibility on my authorization or solely on a refusal to consent to this release of information. The information disclosed may not be in connotation with my/the patient’s treatment. In consideration of this consent, I hereby release the source of the records from any and all liability arising therefrom. This request/authorization is valid solely for this one-time release of information for the specified purpose only and shall expire immediately upon fulfillment of this request.

I affirm that I have the legal authority to authorize the release of my/the patient’s protected health information under federal and state laws governing the confidentiality of health records. I understand that I may void this request/authorization, except for action already taken, at any time by means of a written letter revoking the authorization and transfer of information. I agree that a photocopy, electronic, or faxed copy of this form is acceptable in lieu of the original. I affirm that everything in the form that was not clear to me has been explained, and I also understand that I have the right to receive a copy of this form upon my request.
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