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.
- YesNo

- Requestor Name *
  
  First NameLast Name
- Relationship to Patient*
- Patient Name *
  
  First NameLast Name
- Patient Date of Birth*
  
  MonthDayYear
- Patient Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Patient Email*
  example@example.com
- Patient Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Contact Phone Number (if different)
  Please enter a valid phone number.Format: (000) 000-0000.
- Contact Email (if different)
  example@example.com
- Visit NoteDiagnostic ResultOperative ReportComplete Medical Record (note: may be a very large file; 100+ pages)Billing Record
- Account summary listing the amounts charged and payments received for each date of service)Detailed report for each claim
- YesNo
- Dates of Service (or Range)*
  Please input a specific date, a range of dates, or type "All" for all dates of service
- Method of Delivery*
- Please specify which location you would like to pick up your records
- YesNo
- What address would you like the records to go to?
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Note: If you are requesting your record to be delivered via email, please be sure that you have provided an accurate email address above. Emails will be sent in an encrypted format and you will receive instructions on how to retrieve the information. Federal express will be used to send information via trackable mail. A copy of the receipt will be included with your records and that amount will be charged to your Advanced account.
- 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
- I Understand
- Date*
  
  MonthDayYear
- Name*
  
  First NameLast Name
- Signature*
  
  Clear
- Should be Empty:

Patient Request For Copy Of Medical Or Billing Records

This form is for patients / patient representatives ONLY.