Printable request for medical records
[PDF File]INDIVIDUALS' REQUEST FOR A COPY OF THEIR OWN HEALTH ...
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The purpose of this form is to provide an individual the means to make a written request for a copy of their information maintained by the Department of Veteran Affairs (VA) in accordance with 38 CFR 1.577. The information on this form is requested under Title 38 U.S.C. Your disclosure of the information requested on this form is voluntary.
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
This box must be checked for ALL releases of records authorized by legal representatives. **If other than patient's signature, a copy of legal documents MUST accompany the authorization when presented; the exception is a parent of minors under 18 years of age. SP13018 Authorization for Release of Medical Information (9/16) 803233
[PDF File]Request for Access to/Authorization for Use and Disclosure ...
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I understand that if I am being requested to authorize a use or disclosure that, upon request, I will get a copy of this form after I sign it. I understand my request will be acted upon within 30 days. If I am not provided access or information cannot be supplied, I understand I will be notified, and have
[PDF File]REQUESTING YOUR MEDICAL RECORDS HAS NEVER BEEN …
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to download or print your medical records within 1-3 business days. (You will be invoiced upon receipt from HealthPort Health Service) Note: No postage fees will apply Fax We can fax your key medical record information to another care provider upon your request the same day or prior to your scheduled appointment (At no charge) Mail
[PDF File]MEDICAL RECORD Authorization for the Release of Medical ...
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their medical records. This authorization may be revoked at any time upon your request. If you would like the above named care provider to have such access or update existing care providers, please choose one of the following: Please give the above named care provider authorization to my medical records
[PDF File]*HCH551* - Home | UConn Health
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A patient whom is a minor (age 13 or older) must also sign the authorization, if medical records contain protected information with the exception of Behavioral Health, which requires authorization by the patient if a minor age 16 or older. • Requests for copies of medical records are subject to fees as allowed by law.
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