Medical Records Request

HIPAA empowers individuals to access and obtain copies of their protected health information. Our Health Information Management (HIM) department efficiently processes these requests and provides copies as needed. Any exceptions will be reviewed under 45 CFR §164.524. Your health information is your right—let us assist you in accessing it easily.

Medical Records Request

Step 1 of 4

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Health Information Management Services (Med. Records) Department

Release of patient information consent form

Release to(Required)

Release to Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reason for Release(Required)

Please select applicable consent boxes below

Please read carefully.

I hereby authorize Governor Juan F. Luis Hospital & Medical Center to furnish the above-named individual, company, or attorney with my medical data, including AIDS, HIV test results, sexual abuse, diagnosis, treatment and related information they may request, as listed below, concerning my illness or injury, as per HIPAA law.

I agree

I hereby authorize Governor Juan F. Luis Hospital & Medical Center to furnish the above-named individual, company, or attorney with my medical data, except AIDS, HIV test results, diagnosis treatment and related information, and/or drug abuse and/or psychiatric diagnosis, treatment and related information.

I agree

This consent is subject to revocation by the undersigned at any time except to the extent that action has been take in reliance hereon, and if not earlier revoked, it shall terminate six (6) months from the date fo the consent without express revocation.

I agree

I hereby consent to the release of any and all records containing alcohol and/or sexual/drug abuse and/or psychiatric diagnosis under the same consideration as outlined above. I understand that such information cannot be released without my specific consent, except in accordance with a court order.

I consent

I further understand that I have a right to receive a copy of this authorization upon request.

I understand

Copy Requested(Required)

Yes

Copy Received

Yes

Identifying Information

Patient's Name at Time of Treatment(Required)

First Last

Attending Physician

Date of Birth(Required)

Month

Day

Year

Last 4 of SSN(Required)

Date of Treatment(Required)

Month

Day

Year

Information Requested

Information Requested(Required)

Discharge Summary

History and Physical

Operative Report

X-ray

Consultation

Cardiac Cath Lab Report

Clinical Laboratory

EKG, EEG

Other

Please list other information requested

The above information is release for the following purposes only.(Required)

Continuity of Medical Care

Adoption

Financial Resources

Personal Use

Rehabilitation

Nursing Home Placement

Attorney Use

Hospital Transfer

Insurance

Protective Services

Cert of Hospitalization

Medical Records Authorization(Required)

I authorize the individual, company, or attorney below to obtain copies of my medical records on my behalf.(Required)

Patient, Parent or Legal Guardian(Required)

First Last

Date

Month

Day

Year

Relationship of authorized signer.

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Medical Records Request