[RELEASE REQUEST] ELLIE MARSHALL

[Ellie Marshall]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [] Mrs.
  • [X] Ms.
  • [] Other
  First Name:
  Ellie
  
  Middle Name: (optional)
  Ashley Louise
  
  Last Name:
  Marshall
  
  Gender: (select one)
  • [] Male
  • [X] Female
  Date of Birth:
  31/AUG/2001
  
  Address:
  Floor One, Room Fourteen of 101 Occupation Avenue, Los Santos, San Andreas
  
  ZIP / Postal Code:
  N/A
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  390102
  
  Email:
  [email protected] (( Misuzu ))
  

III. RELEASE INFORMATION

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

• 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: 31/AUG/2001
  • To: 27/NOV/2022

• Medical Records to be Released: (check all that apply)
  • [] Emergency Room Visit (ER notes, progress notes, consultations, procedure notes, test results)
  • [] 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)
  • [] Clinic, Office Visit or Immediate Care (Office notes, progress notes, procedure notes, test results)
  • [X] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
  • [] Other Records: (specify here)
  
  

IV. AUTHORIZATION FOR RELEASE INFORMATION

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• I, ELLIE ASHLEY LOUISE MARSHALL, 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, ELLIE ASHLEY LOUISE MARSHALL, 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, ELLIE ASHLEY LOUISE MARSHALL, 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, ELLIE ASHLEY LOUISE MARSHALL, 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, ELLIE ASHLEY LOUISE MARSHALL, 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:
  
  
  Date:
  27/NOV/2022

[Mikey Lions]

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• Dear Ms. Marshall,
  
  We've received your request and the medical reports of the patient Ellie Marshall have been sent via electronic release considering that the patient herself gave written and signed consent to release of the reports that were made after her medical records, according to HIPAA laws requirements.
  
  As signed, the reports that have been released are not complete and, therefore, do not represent the whole evolution of the patient's treatment. Pillbox Hill Medical Center is not responsible for the posterior use given to the released documentation. The report cannot be considered as a sworn statement.
  
  Kind regards,