Cardiovascular Interventions New Patient Medical Request Form

MEDICAL RECORDS REQUEST OR RELEASE FORM
FIRST NAME*
MIDDLE INITIAL
LAST NAME*
DATE OF BIRTH*

MonthDayYear
Date
Do you need to request or send your medical records to another physician?*

No, I do not need to complete this form.Yes, I do need my Medical records.
By selecting No, you are stating that you do not need to request or receive your medical records from any other doctor or medical facility.

PLEASE NOTE: If you need your medical records from previous physicians, practices, or hospitals and do not request them now, this could possibly result in the rescheduling of your appointment to a later time. Please sign & date below.
HIPAA/BILLING AUTHORIZATION FOR USE OR DISCLOSURE OF PERSONAL HEALTH INFORMATION (PHI)

This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards. The medical records may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. The medical records may contain information concerning HIV testing and/or AIDS diagnosis or treatment. The medical records may contain information concerning or related to billing for. Separate consent must be given to have this information released.

Please complete, digitally sign and click submit so that we can procure any of your medical records prior to your appointment.
PRIMARY CARE PHYSICIAN

REQUESTING My Records orSEND My Records
Primary Care Physician Name
Phone
Fax
Do you want to add another Primary Care Physician?*

YesNo
Primary Care Physician 2 Name
Phone 2
Fax 2
PREVIOUS CARDIOLOGIST

REQUESTING My Records orSEND My Records
Cardiologist Name
Phone
Fax
Do you want to add another previous Cardiologist?*

YesNo
Cardiologist 2 Name
Phone 2
Fax 2
OTHER PHYSICIAN

REQUESTING My Records orSEND My Records
Other Physician
Phone
Fax
Do you want to add another Other Physician?*

YesNo
Other Physician 2
Phone 2
Fax 2
HOSPITAL

REQUESTING My Records orSEND My Records
Hospital
Location
Fax
Do you want to add another Hospital?*

YesNo
Hospital 2
Location 2
Fax 2
Signature*

Clear
Date*

MonthDayYear
Date
If you have digital records you would like to submit now, you can attach them by clicking here. Otherwise we will obtain your records from your healthcare providers.

Cancelof
If you have digital records you would like to submit now, you can attach them by clicking here. (optional)

Cancelof
Should be Empty:

MEDICAL RECORDS REQUEST OR RELEASE FORM