Hope - HIPAA Release Medical Record Request

HIPAA Release Medical Record Request

INFORMATION TO BE RELEASED FROM

Phone:

PRIMARY CARE PHYSICIAN RELEASE

Primary Care Physician
It may be important for your physician to receive records from Hope Clinical Research (HCR). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from HCR, a signed authorization form must be received. Without your authorization, HCR will not release any information.

MUST SELECT AT LEAST ONE OPTION

Release

I DO authorize HCR to release all study related records to the physician above.

I DO NOT authorize HCR to release any study related records to the physician above.

I DO NOT have a Primary Care Physician

HOPE CLINICAL RESEARCH RELEASE

Hope Clinical Research
It may be important for HCR to contact your physician and/or receive medical records from your physician in order for us to determine your eligibility for the study. In order for HCR to contact or receive medical records from your physician, a sign authorization form must be completed. Without your authorization, we will not contact or request medical records from your physician.

MUST SELECT AT LEAST ONE OPTION

HCR Release

I DO authorize my personal physician to provide my medical records to HCR.

I DO NOT authorize my personal physician to provide my medical records to HCR.

I authorize the release of my STD results, HIV/AIDS, ALCOHOL/SUBSTANCE ABUSE testing, as defined by law, RCW 70.24 et seq., whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes

PLEASE READ CAREFULLY

The undersigned hereby authorizes the release of their medical records and/or demographics information including their name, address and phone number to HCR and their affiliates as it pertains to any/all clinical research studies. All information provided will remain with HCR and its affiliates. A photocopy of this authorization shall be the same authority as the original.

Proprietary and Confidential | Version 3.0 (01NOV2018)

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

June 8, 2016 3:22 pm PDT

Hope - HIPAA Release Medical Record Request Uploaded by Sasson Sarooei Sarooei - [email protected] IP 76.214.69.88

May 25, 2023 10:14 am PDT

Hope Recruitment - [email protected] added by Sasson Sarooei Sarooei - [email protected] as a CC'd Recipient Ip: 76.214.69.88