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

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.
 

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 demographic 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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Signature Certificate
Document name: Excel Clinical Research - HIPAA Release Medical Record Request
Unique Document ID: d78e09bc18d8d5a8208262597cc662753379be72
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 98.152.154.117