Patient Request For Copy Of Medical Or Billing Records

Patient Request For Copy Of Medical Or Billing Records
This form is for patients / patient representatives ONLY.

IMPORTANT: If you need your office visit notes and / or operative reports sooner than 30 days, they can be downloaded directly from the PATIENT PORTAL.

Preliminary Information
Are you the patient / legal patient representative requesting office visit notes and / or operative reports?*

YesNo

Release Disclosure
By checking the box, entering your name below and clicking "Submit", you are certifying that you have requested medical and / or billing information from Advanced Urology. These records may contain information related to the treatment of physical and / or mental illness, chemical dependency or alcohol abuse, testing and / or treatment of communicable or infectious disease (i.e. sexually transmitted infections, HIV, AIDS). You accept responsibility for the release of this information to you and to any others to whom you further disclose the same.*

I Accept Responsibility
By checking the box, you understand that requests for medical / billing records may take up to 30 days.*

I Understand
Date*

MonthDayYear
Name*

First NameLast Name
Signature*

Clear
Should be Empty:

This form is for patients / patient representatives ONLY.