[RELEASE REQUEST] Charles Castellanos

[Charles Castellanos]

I. PATIENT INFORMATION

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• Title: (select one)
  • [x] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Charles
  
  Middle Name: (optional)
  -
  
  Last Name:
  Castellanos
  
  Gender: (select one)
  • [c] Male
  • [] Female
  Date of Birth:
  02/SEP/1984
  
  Address:
  105 Spanish Avenue
  
  ZIP / Postal Code:
  2024
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [] Mobile
  • [] Home
  • [x] Work
  • [] Other
  Phone Number:
  07333782
  
  Email:
  [email protected] (( Charles Castellanos ))
  

III. RELEASE INFORMATION

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• Purpose of Medical Information Release:
  • [] Further Treatment / Continued Care
  • [x] Personal Use
  • [] Attorney / Client
  • [x] Other: (Evidence in trial)

• 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: 19/FEB/2023
  • To: 20/FEB/2023

• Medical Records to be Released: (check all that apply)
  • [x] 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)
  • [] Psychology Visits (Office notes, progress notes, procedure notes, evaluation results)
  • [] Other Records: (specify here)
  
  

IV. AUTHORIZATION FOR RELEASE INFORMATION

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• I, Charles Castellanos, 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, Charles Castellanos, 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, Charles Castellanos, 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, Charles Castellanos, 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, Charles Castellanos, 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:
  C. CASTELLANOS
  
  Date:
  20.FEB.2023

[Charles Castellanos]

(( I was transported to PHMC ER by LSFD Rescue 72, Elizabeth Walker.

Fire Rescue-72, I am inbound with a green victim, blunt force trauma to the head from close range. Vitals are normal, bleeding is stopped.

Presenting injury was a laceration to the back of the head from having a rock thrown at me. Treatment applied prior to hospital arrival was gauze/pressure, then booked in at PHMC ER for treatment, had to be NPCed as nobody around. Would like in a cool format as suspect has pleaded not guilty and will go to trial ))

[Mikey Lions]

(( We don't do NPC medical reports. I will not put anyone through the burden of creating a medical report for something that has been NPCed and that our staff hasn't done. Furthermore, reports are optional and always a chance to give RP opportunities to our staff, so you may need to /do it. I am really sorry, but our reports have serious consequences, and our staff takes these very seriously, and we can't just do a report on something without a proper IC examination. Hope the answer helped ))