DM-ROI - PDF FORM V6

Release of Protected Health Information Authorization

This form will allow DM Clinical to request your medical records from your healthcare provider(s)
DM Clinical Research DM Clinical Research 13414 Medical Complex Dr. 13406 Medical Complex Dr. Tomball, TX 77375 Tomball, TX 77375

Martin Diagnostic Clinic 710 Lawrence St Tomball, TX 77375

Rheumatology Clinic of Houston 17134 N. Eldridge Pkwy Suite A, Tomball, TX 77377
Instructions For You From Our Team
Your First Name
Your Last Name
CRIO ID
Comtrak ID
Your Telephone Number
If Pre-filled, please check if it is correct.Format: (000) 000-0000.
Your Date of Birth

MonthDayYear
Date
Your Doctor's Name 1
Enter the name of your Doctor (who has the medical records we have requested)
Your Doctor's Facility Name 1
Enter the name of your Doctor (who has the medical records we have requested)
Doctor's Facility's Fax Number 1
Optional
Doctor's Facility's Phone Number 1
OptionalFormat: (000) 000-0000.
Doctor Name 2
If more than one Doctor has the records we have requested, please enter the name of the other Doctor/facility here.
Facility Name 2
Enter the name of your Doctor (who has the medical records we have requested)
Doctor/Facility's Fax Number 2
Optional
Doctor/Facility's Phone Number 2
OptionalFormat: (000) 000-0000.
Doctor Name 3
Doctor's Facility Name 3
Enter the name of your Doctor (who has the medical records we have requested)
Doctor/Facility's Fax Number 3
Optional
Doctor/Facility's Phone Number 3
OptionalFormat: (000) 000-0000.
Start Date For Records

MonthDayYear
Please enter the date from which the relevant records were recorded (It is preferable to enter an earlier date than a later one)
Site
DM Doctor Name
The following record(s) are being requested.

Other
Progress Notes Details
Lab And Imaging Reports Details
Medication List (Including Vaccines) Details
Please note that DM Clinical Research and our doctors will request access to your medical recods to evaluate your eligibility and ensure your safety for our clinical trials.

By signing this document you declare the following:

I, the undersigned, have read the above and authorize the facility named above to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time, except to the extent that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above-named facility and its parent company from all the liability and damages resulting from the lawful release of my Protected Health Information (PHI
Signature of Patient/Parent/Guardian Authority
Relationship to Patient
Today's Date

MonthDayYear
Today's Date
This authorization will expire one year from the date this form is signed.
Prescreen ID
Should be Empty:

Release of Protected Health Information Authorization