[RELEASE REQUEST] Maartje Janssen

[cratt21]

I. PATIENT INFORMATION

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• Title:
  • [] Mr.
  • [] Mrs.
  • [X] Ms.
  • [] Other
  First Name:
  Maartje
  
  Middle Name:
  N/A
  
  Last Name:
  Janssen
  
  Gender: )
  • [] Male
  • [X] Female
  Date of Birth:
  07/SEP/1997
  
  Address:
  Perrara Motel Room 16
  
  ZIP / Postal Code:
  N/A
  

II. CONTACT INFORMATION

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• Phone Type:
  • [X] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  75980772
  
  Email:
  [email protected] (( cratt21 ))
  

III. RELEASE INFORMATION

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• Purpose of Medical Information Release:
  • [] Further Treatment / Continued Care
  • [] Personal Use
  • [] Attorney / Client
  • [X] Other: Tint Exemption Application

• 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: 01/JAN/2024
  • To: 01/JAN/2024

• 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)
  • [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, Maartje Janssen, 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, Maartje Janssen, 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, Maartje Janssen, 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, Maartje Janssen, 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, Maartje Janssen, 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. Janssen
  
  Date:
  01/JAN/2024

[Kaden Malik]

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Dear Ms. Maartje Janssen

We have received your request for the release of your medical records. Please be advised that there is a processing fee associated with this service.

To proceed with the request, kindly make a payment of $5,000 for the medical record release fee via bank transfer Pillbox Hill Medical Center through our routing number 020000062 and attach proof of payment below. Once the payment is received, we will promptly process your request and release the requested medical records.

If you have any questions or concerns regarding the payment, feel free to contact us at 50056 or send an email to our administrative department.

Kind regards,
Kaden Malik
Medical Administrative Department
Pillbox Hill Medical Center

[cratt21]

Proof of payment:

https://i.imgur.com/WkybRYS.png

[Kaden Malik]

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Dear Ms. Janssen,

We are pleased to inform you that we have received your payment for the release of your medical records. Your transaction has been successfully processed, and we appreciate your prompt cooperation.

As per your request, we have attached the requested medical records to the email we sent you. If you have any further requests or if there's anything else we can assist you with, please don't hesitate to let us know.

Kind regards,
Kaden Malik
Medical Administrative Department
Pillbox Hill Medical Center