Excel Clinical Research

Excel Clinical Research - 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 Excel 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

  Release

 

EXCEL CLINICAL RESEARCH RELEASE

Excel Clinical Research
It may be important for ECR 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 ECR 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

ECR Release

Proprietary and Confidential | Version 1.0 (1AUG2014)

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Excel Clinical Research http://excelresearchclinic.com
Signature Certificate
Document name: Excel Clinical Research - HIPAA Release Medical Record Request
Unique Document ID: 1ddc637408e1622225f1e11d77821e7bb3f0da2a
Timestamp Audit
June 8, 2016 3:22 pm PDTExcel Clinical Research - HIPAA Release Medical Record Request Uploaded by Excel Excel Research - info@excelresearchclinic.com IP 104.182.58.26