Page 1 of 1

[FORM] Request your Medical Record

Posted: Thu Apr 11, 2024 5:31 am
by Aurora Farace

Image


I. PATIENT INFORMATION


  • Full Name:
    ANSWER

    Date of Birth:
    DD/MMM/YYYY


    Gender:
    • [] Male
    • [] Female
    • [] Other: (state what here)

    Address:
    ANSWER

    Phone Number:
    ANSWER

    Email Address:
    ANSWER (( Include your GTA World forum name & Discord username here. ))




II. RELEASE DETAILS


  • Purpose of Request: (e.g. personal use, continuation of care, legal proceedings, disability claims, etc.)
    ANSWER

    Dates of Treatment: (provide the specific date range for which you are requesting records)
    ANSWER

    Type of Records Requested: (e.g. treatment progress notes, therapy session summaries, medication management records, psychological assessments, substance abuse treatment plans, discharge summary, lab test results, etc.)
    ANSWER

    Method of Delivery:
    • [] Mail (records will be sent to the address provided)
    • [] Email (records will be sent encrypted to the email address provided)
    • [] In Person Pickup (records can be picked up at our facility during designated hours)
    • [] Other: ANSWER
    Recipient Information: (if the records are to be sent to a specific recipient, please provide their name, organization (if applicable), contact information, and any relevant details)
    ANSWER



III. AUTHORIZATION AND SIGNATURE


  • I, [Your Full Name], hereby authorize Valentines Rehabilitation Center to release my records as requested above. I understand that the information disclosed may include sensitive details about my health and treatment, and I consent to the release of this information for the specified purpose(s) outlined in this form.

    I understand that my medical records are confidential and protected by federal and state privacy laws. I acknowledge that Valentines Rehabilitation Center will make reasonable efforts to ensure the security and privacy of my health information during the release process.

    I further understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I release Valentines Rehabilitation Center and its staff from any liability associated with the release and subsequent use of my medical records by authorized recipients.


    Signature:
    ANSWER

    Date:
    DD/MMM/YYYY




Re: [FORM] Request your Medical Record

Posted: Thu Apr 11, 2024 5:31 am
by Aurora Farace

Title Template:

Code: Select all

[RELEASE REQUEST] YOUR FULL NAME
Post Template:

Code: Select all

[divbox=#303544][center][br][/br][img]https://i.imgur.com/6WhFHLO.png[/img][br][/br][/center][/divbox][br][/br]
[divbox=#363E54][br][/br][left][color=#47AEBF][size=120][b][indent][center]I. PATIENT INFORMATION[/center][/indent][/b][/size][/color][/left][br][/br][/divbox]
[divbox=#303544][br][/br]
[list=none][b]Full Name:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Date of Birth:[/b]
[size=85][i]DD/MMM/YYYY[/i][/size][br][/br][br][/br]
[b]Gender:[/b]
[size=85][list=none]
[*][] Male
[*][] Female
[*][] Other: [i](state what here)[/i][/list][/size]
[b]Address:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Phone Number:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Email Address:[/b]
[size=85][i]ANSWER (( Include your GTA World forum name & Discord username here. ))[/i][/size][br][/br][br][/br][/list][br][/br][/divbox][br][/br]
[divbox=#363E54][br][/br][left][color=#47AEBF][size=120][b][indent][center]II. RELEASE DETAILS[/center][/indent][/b][/size][/color][/left][br][/br][/divbox]
[divbox=#303544][br][/br][list=none][b]Purpose of Request:[/b] [size=70][i](e.g. personal use, continuation of care, legal proceedings, disability claims, etc.)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Dates of Treatment:[/b] [size=70][i][/i][/size] [size=70][i](provide the specific date range for which you are requesting records)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Type of Records Requested:[/b]  [size=70][i](e.g. treatment progress notes, therapy session summaries, medication management records, psychological assessments, substance abuse treatment plans, discharge summary, lab test results, etc.)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Method of Delivery:[/b] 
[list=none][size=85][*][] Mail [size=70][i](records will be sent to the address provided)[/i][/size]
[*][] Email [size=70][i](records will be sent encrypted to the email address provided)[/i][/size]
[*][] In Person Pickup [size=70][i](records can be picked up at our facility during designated hours)[/i][/size]
[*][] Other: [size=85][i]ANSWER[/i][/size][/size][br][/br][/list]
[b]Recipient Information:[/b] [size=70][i](if the records are to be sent to a specific recipient, please provide their name, organization (if applicable), contact information, and any relevant details)[/i][/size]
[size=85][i]ANSWER[/i][/size][br][/br][br][/br][/divbox][br][/br]
[divbox=#363E54][br][/br][left][color=#47AEBF][size=120][b][indent][center]III. AUTHORIZATION AND SIGNATURE[/center][/indent][/b][/size][/color][/left][br][/br][/divbox]
[divbox=#303544][br][/br][list=none]
I, [Your Full Name], hereby authorize Valentines Rehabilitation Center to release my records as requested above. I understand that the information disclosed may include sensitive details about my health and treatment, and I consent to the release of this information for the specified purpose(s) outlined in this form.

I understand that my medical records are confidential and protected by federal and state privacy laws. I acknowledge that Valentines Rehabilitation Center will make reasonable efforts to ensure the security and privacy of my health information during the release process.

I further understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. I release Valentines Rehabilitation Center and its staff from any liability associated with the release and subsequent use of my medical records by authorized recipients.[br][/br][br][/br]
[b]Signature:[/b]
[size=85][i]ANSWER[/i][/size][br][/br]
[b]Date:[/b]
[size=85][i]DD/MMM/YYYY[/i][/size][br][/br]
[br][/br][/divbox][br][/br]