Authorization to release medical records

Name of Patient:(Required)

First Last

Previous Name:

Address(Required)

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

Date of Birth:(Required)

1. I am requesting from Doctor’s Choice Home Care (“DCHC”) to:(Required)

inspect

obtain a copy

of the following health information that is maintained in a designated record set by DCHC:

Health Information(Required)

Complete home health medical record with Plan of Care/Orders

Hospital/SNF/Other Facility discharge records Treatment Notes

Billing/Invoice

Other health information:

Complete home health medical record Date(s) of Service:

Start Date

End Date

Hospital/SNF/Other Facility discharge records Treatment Notes Date(s) of Service:

Start Date

End Date

Billing/Invoice Date(s) of Service:

Start Date

End Date

Other health information Date(s) of Service:

Start Date

End Date

Please Specify Other Health Information:

2. I am requesting that DCHC send a copy of my records in the following format. I understand that DCHC will provide access to my records in the form and format that I request only if DCHC determines that it is readily producible in such form or format.(Required)

Paper. If the preferred format is not readily producible, the access will be provided in a readable hard copy form or other such agreed upon form.

Electronic. If the preferred electronic format is not available in a readily producible by DCHC, DCHC will make the information available in an agreed upon alternative, readable electronic format.

Electronic Format:

Word

PDF

Excel

Other (USB, CD, Other):

Please Specify Other Electronic Format:

3. I am requesting DCHC to send my records in the following manner. I understand that DCHC will use best efforts to deliver records in the manner that I request.(Required)

Email (Encrypted): In an effort to protect your health information, our standard practice is to encrypt our email.

US Mail:

In-Person Pickup

Other

Email Address:

US Mailing Address

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

Please Specify Other Delivery Method for Records

4. I am requesting that my records (in the above-indicated format) be sent to the following individual:

Name

First Last

Address

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

Phone

(Only if requesting records to be sent via email)

I hereby request DCHC to provide me with access to my health information that DCHC holds about me in the DCHC designated record set in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I understand that DCHC has 30 days to respond to this request and that DCHC may extend this 30-day response period for another 30 days if, within the initial 30-day period, DCHC provides me with a written statement of the reasons for the delay and the date by which it will respond. I understand that in certain circumstances DCHC may deny my request.

I also understand that DCHC may charge a reasonable fee associated with copying (including the cost of supplies and labor), postage (if you want the records mailed to you), and, if requested, for preparing a summary or explanation of any records. These fees are described in the Schedule of Charges attached to this form.

Signature of Patient/Legal Representative(Required)

Today's Date(Required)

Print Patient Name /Legal Representative Name(Required)

First Last

Today's Date(Required)

If signed by the patient’s personal representative, explain authority to act on behalf of the patient:

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