MEDICAL RECORDS REQUEST | GoldStar Urgent Care

Records to be released to:

Address of Healthcare Provider / Physician / Facility, etc

Country/Region

Address

City

Zip / Postal code

Patient's First Name:

Patient's Last Name:

Patient's Date of Birth:

Patient's Social Security Number:

I authorize and request the disclosure of all protected information for the purpose of review and evaluation.

I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse's notes, clinic records, treatment plans, documents, correspondence, test results, statements, questionnaires/histories, correspondence, etc

All laboratory, histology, cytology, pathology, immunohistochemistry records and specimens; radiology records and images and echocardiogram results.

All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period

From Dates:

To Dates:

I understand the information to be released or disclosed may include information relating to sexually transmitted

diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and

drug abuse. I authorize the release or disclosure of this type of information.

This protected health information is disclosed for the following purposes:

Records to be sent via:

Secure Email

Fax

I understand that:

a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released

in reliance upon this authorization.

b. The information released in response to this authorization may be re-disclosed to other parties.

c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein.

This authorization shall be in force and effect until two years from date of execution at which time this authorization

expires.

Signature of Patient or Legally Authorized Representative Date (See 45CFR § 164.508(c)(1)(vi))

Name and Relationship of Legally Authorized Representative to Patient (See 45CFR §164.508(c)(1)(iv))

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