Healthcare Data Request Verification

HEALTHCARE DATA REQUEST VERIFICATION

Patient Name:    Date of Birth:

Medical Record Number:    Patient Phone:

Request Details

Date of Request:

Data Requested (select all that apply)

Medical records (clinic notes, hospitalization records)

Billing and payment records

Imaging and radiology reports

Laboratory and pathology reports

Mental health / behavioral health records (if applicable)

Substance use treatment records (if applicable)

From:    To:

Proof of Identity & Verification

Proof of identity provided (check all presented):
State-issued photo ID    Passport    Health insurance card    Other:

Authorization, Certifications, and Notices

By signing below I certify that I am the patient identified above or the patient's duly authorized representative. I expressly authorize the release of the categories of protected health information checked above to the requestor named on this form for the purpose stated. This authorization includes disclosure of information created by or in the possession of the facility, including records related to diagnosis, treatment, and billing, except where prohibited by law.

I understand that my records may include information regarding mental health treatment, substance use disorder treatment, HIV/AIDS status, or genetic testing where applicable, and I authorize their disclosure unless I have explicitly excluded those categories in writing below.

I understand that I may revoke this authorization at any time by providing a written revocation to the health records office, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

Delivery & Security

Desired delivery method (select one):
U.S. Mail to address below
Office pickup by requestor
Secure patient portal
Encrypted electronic delivery to recipient below

HIPAA / Privacy Acknowledgment

I acknowledge that I have received and read the facility's notice of privacy practices and understand my rights regarding my protected health information. I understand that signing this form is my authorization to disclose the information described above.

I acknowledge and agree

Staff Verification (for facility use)

Sign Now