Release of A Personal Choice Medical Records

Release of A Personal Choice Medical Records

Use this form if you are requesting your surgery records from A Personal Choice
By submitting this release you are authorizing A Personal Choice PA to send your reversal surgery records to the entity indicated by you.

After you pay the records fee and click "Submit" our office will recieve your request.

Your request will be processed within 72 business hours.

You will be notified when your records request has been completed.
If you are requesting records for your medical care most doctors will only need to see the operative note and MD letter of recommendations.

Sending your doctor your entire medical record may not be helpful.

If you are requesting records for your attorney they will want your entire medical record.
What records are you requesting?*

Operative note + MD letter of recommendations.Entire medical record from my treatment at A Personal ChoicePayment receipt
Please be aware any medical records sent may have your complete medical history and could contain HIV related information, pregnancy history, sexually transmitted infection information, psychiatric information, and/or drug and alcohol abuse information.*

I understand
Reason for record request:*
All records will be password protected with the year of your birth.

For example, if you birth date was March 1st 1980, then we will password protect your records with the password of "1980".
Where would you like your records be sent? (select one)*

To me (the patient)To my healthcare providerTo my attorney
Our office will only send records to patients by email.
Send my records to my healthcare provider or attorney by:*

EmailFax
Enter the name of the person receiving your records:*
It is your responsibility to provide an accurate email address, phone number, and/or fax number.

Our staff is not responsible for verifying the correct email address or fax number.
What health care provider/attorney email address should we send your records to?

Confirmation Emailexample@example.com
Phone number of your healthcare provider or attorney:
Please enter a valid phone number.
Fax number of your healthcare provider or attorney:
Please enter a valid phone number.
Do you have any comments for our staff?
I understand a request for medical records will require a $35 fee.*

I understand
Emailed documents will be sent in a PDF format and will be password protected with the year of your birth. If you were born May 1st 1980... your password will be "1980."*

I understand
Enter your name as it appears on your records at our facility.*

First NameLast Name
Enter your date of birth:*

MonthDayYear
Date
Please upload an image of the front of your photo ID (ie driver's license).*

Cancelof
Our office will contact you by phone to verify your request, date of birth, and date of surgery before sending medcial records.
Best phone number to contact you*
Please enter a valid phone number.
Best email to notify you when records sent*

Confirmation Emailexample@example.com
Patient signature*

Clear
Date*

MonthDayYear
Date
A 3.99% card processing fee is added to all credit, health savings account, and flexible spending account card transactions.

Medical Records Fee

$36.40

Total

$0.00

Credit Card

Is the credit card being used to submit this form in the patient's name or another person's name?*

This credit card is in my name (the patient)This credit card is in another person's name (someone who is not the patient)?
What is the name of the person on the credit card being used to pay the scheduling fee and submit this form?*

First NameLast Name
Staff Documentation of Records Release
Staff will need to call patient and verify records request:

Please verify:

1. Request

2. Patient name

3. Date of birth

4. Date of surgery
I confirmed the name on the photo ID uploaded to this form matched the name and date of birth in the patient's medical record:*

Confirmed uploaded name and date of birth on photo ID matched patient's name and date of birth in the medical record
I confirmed the patient's date of surgery:*

Confirmed uploaded name and date of birth on photo ID matched patient's name and date of birth in the medical record
Records were password protected with the year of patient's birth (ie 1980):*

I confirm I password protected records with the year of patient's birth
What records were sent?*

Entire medical recordPayment receiptOperative note + MD letter of recommendations
Please remember to password protect records with the year of patient's birth.

When sending records remember to notify the recipient records are password protected with the year of patient's birth in four (4) digits....so for example April 1st 1990 would be password protected with "1980"
Records were sent to?*

PatientHealthcare provider indicated aboveAttorney indicated above
How were records sent?*

Email address entered aboveFax number entered above
Who were records sent to:*
Patient notified by:*

Phone: left messagePhone: spoke with patientEmail
Date records were sent*

MonthDayYear
Date
Staff member's name*

First NameLast Name
Staff signature*

Clear
Date*

MonthDayYear
Date
Patinet will get automated email once this request is complete.

Please save this form in patient's electronic medical chart.

Archive this form in JotForms.
Should be Empty:

Release of A Personal Choice Medical Records

Credit Card

Staff Documentation of Records Release