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Medical Records Release
AUTHORIZATION FOR THE RELEASE OF HEALTH INFORMATION FROM OTHER HEALTHCARE FACILITIES
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Social Security Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person/Organization to Receive Information
Organization to Receive Information
Address
City
State
Zip Code
Phone Number
Fax Number
I, the undersigned, authorize any healthcare provider or facility that has rendered care to me to release my medical records and to hereby authorize PIONEER CLINICAL STUDIES, INC., to obtain the health information indicated below that is contained in my patient records to the Recipient named above. The information released in response to this authorization may be re-disclosed to other Business Associates. I understandand acknowledge that this may include treatment for physical and mental illness, genetic testing information, alcohol/drug abuse, and or HIV/AIDS testresults or diagnoses. This authorization does not include permission to release outpatient Psychotherapy Notes. The release of Psychotherapy Notes requires aseparate authorization. Psychotherapy Notes are defined as notes that document private, joint, group, or family counseling sessions that are separated from the rest of a patient’s medical record.
Release Details
Check All That Apply, I, the patient, authorize and request the disclosure of all protected information I select below full and complete.
*
Complete Record
Physical Therapy
Laboratory Reports
Radiology Reports
Pathology Reports
EKGs
Last Consult Encounter
This consent is subject to revocation at any time except to the extent the action has been taken thereon. This authorization and consent will expire one year from the date of authorization written below. Your health care (or payment for care) will not be affected by whether you sign this authorization or not. Once your health care information is released, redisclosure of your health care information by the Recipient may no longer beprotected by law.
Date Signed
*
-
Month
-
Day
Year
Signature of Patient or Legal Representative
*
Printed Name
*
Relationship if not Patient
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