[Release Request] Mia Perez

[Mia Perez]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [X] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Mia
  
  Middle Name: (optional)
  Sabella
  
  Last Name:
  Perez
  
  Gender: (select one)
  • [] Male
  • [X] Female
  Date of Birth:
  25/AUG/2003
  
  Address:
  Tinsel Tower - Floor 13, Room 2
  
  ZIP / Postal Code:
  N/A
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  8779
  
  Email:
  [email protected] (( Include forum name in brackets ))
  

III. RELEASE INFORMATION

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• Purpose of Medical Information Release:
  • [] Further Treatment / Continued Care
  • [] Personal Use
  • [] Attorney / Client
  • [X] Other: (Police information)

• Format of Medical Information Release:
  • [] Copy of Record to be picked up
  • [] Verbal Release (e.g. phone conversation)
  • [X] Electronical Release (sent via email)
  • [] Other: (specify here)

• Date Range:
  I authorize the release of information covering the period(s) of treatment:
  • From: 07/AUG/2022
  • To: 07/AUG/2022

• Medical Records to be Released: (check all that apply)
  • [X] Emergency Room Visit (ER notes, progress notes, consultations, procedure notes, test results)
  • [X] Hospital Stay (History and physical, progress notes, consultations, operative reports, discharge summary, test results)
  • [] Outpatient Surgery/Procedure (History and physical, progress notes, consultations, procedure notes, test results)
  • [X] Clinic, Office Visit or Immediate Care (Office notes, progress notes, procedure notes, test results)
  • [] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
  • [] Other Records: (specify here)
  
  

IV. AUTHORIZATION FOR RELEASE INFORMATION

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• I, Mia Perez, hereby authorize Pillbox Hill Medical Center to disclose my individually identifiable health information. I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care will not be affected if I do not sign this form.
  
  I, Mia Perez, understand that if the recipient authorized to receive the information is not a covered entity, the released information may no longer be protected by federal and state privacy regulations.
  
  I, Mia Perez, further understand that I may revoke this authorization at any time by notifying, in writing, the Pillbox Hill Medical Center facility where this authorization is being signed. I also understand the revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any releases made prior to the receipt of the written revocation.
  
  I, Mia Perez, understand the record might not be complete, if it is a recent visit, and additional documentation could be added after submitting this request.
  
  By typing my name below, I, Mia Perez, certify that this information can be used for the purpose of processing my Authorization for Medical Records Release request. I consider this as my electronic signature for this request.
  
  

• Signature:
  M.Sabella Perez
  
  Date:
  07/AUG/2022

[Mikey Lions]

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• Dear Ms. Perez,
  
  We've received your request. However, there are no medical reports within the requested dates.
  
  Warmest regards,