Hope Clinical Research

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

 

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

Proprietary and Confidential | Version 1.0 (1AUG2014)

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Hope Clinical Research https://hopeclinical.com
Signature Certificate
Document name: Hope - HIPAA Release Medical Record Request
Unique Document ID: 0d4558cf3552fd70d13962ba2bd4346813947d19
Timestamp Audit
June 8, 2016 3:22 pm PSTHope - HIPAA Release Medical Record Request Uploaded by Sasson Sarooei Sarooei - info@hopeclinical.com IP 104.182.58.26