Healthcare Clinic Request

HEALTHCARE CLINIC REQUEST

Request Type

Please indicate the primary purpose of this request (select all that apply and provide details below):

Appointment / Scheduling

Referral to Specialist

Release / Transfer of Medical Records

Billing / Insurance Inquiry

Other

Patient Information

Patient Full Legal Name:

Insurance Information

Medical History & Current Information

Records / Release Authorization (If applicable)

I authorize the release and exchange of my protected health information as reasonably necessary to fulfill the request indicated above. This authorization includes, where applicable, clinical notes, imaging reports, laboratory results, and billing information.

Unless a specific date is provided above, this authorization will expire ninety (90) days from the date signed below or upon completion of the requested action, whichever occurs first. I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

Administrative & Legal Acknowledgements

Consent to Request and Treatment: By signing below I request the clinic to process this request and, where applicable, to provide treatment, coordination of care, or referral services. I consent to necessary administrative actions to carry out the requested service, including communication with other health care providers and insurers.

Release of Liability for Processing: I acknowledge that processing of this request may be subject to clinic scheduling availability, third-party provider response time, and insurer requirements. The clinic is authorized to release or obtain medical information only as necessary to fulfill this request. The clinic is not responsible for delays caused by third parties.

Payment Responsibility: I accept financial responsibility for any non-covered services, copayments, or fees associated with the requested service unless otherwise determined by my insurer. Certain requests (for example, copying of records) may incur administrative fees consistent with clinic policy.

HIPAA Acknowledgement: I acknowledge that I have received or been offered the clinic's Notice of Privacy Practices and understand my rights with respect to protected health information. I understand that information released pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations.

Accuracy Certification: I certify under penalty of perjury that the information provided on this form is true, complete, and accurate to the best of my knowledge.

Preferred Scheduling / Urgency

Urgency of Request:

Additional Authorizations / Notes

If signing as an authorized representative, provide legal relationship and attach documentation evidencing authority (e.g., power of attorney, court order).

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