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HIPAA Release Medical Record Request

INFORMATION TO BE RELEASED FROM

Phone:

PRIMARY CARE PHYSICIAN RELEASE

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

MUST SELECT AT LEAST ONE OPTION

PCP Release

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

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

I DO NOT have a Primary Care Physician.

EPIC CLINICAL RESEARCH RELEASE

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

MUST SELECT AT LEAST ONE OPTION

ECR Release

I DO authorize my personal physician and/or Medical Center to provide my medical records to ECR.

I DO NOT authorize my personal physician and/or Medical Center to provide my medical records to ECR.

I DO NOT have a Primary Care Physician and/or Medical Center.

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

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED, AND CAN BE REVOKED IN WRITING AT ANY TIME. I UNDERSTAND I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION AND THAT ANY REFUSAL TO SIGN IT WILL NOT AFFECT MY ENROLLMENT IN A HEALTH PLAN OR ELIGIBILITY FOR HEALTH BENEFITS.

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

Proprietary and Confidential | Version 3.0 (19OCT2018)

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Timestamp

Audit

December 1, 2021 2:54 pm PDT

HIPAA Release Medical Record Request Uploaded by Epic Clinical Research - [email protected] IP 76.214.69.88

May 25, 2023 9:55 am PDT

Epic Recruitment - [email protected] added by Epic Clinical Research - [email protected] as a CC'd Recipient Ip: 76.214.69.88