[RELEASE REQUEST] Eric Contreras

[Madelynn Lawson]

I. PATIENT INFORMATION

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• Title: (select one)
  • [X] Mr.
  • [] Mrs.
  • [] Ms.
  • [] Other
  First Name:
  Eric
  
  Middle Name: (optional)
  N/A
  
  Last Name:
  Contreras
  
  Gender: (select one)
  • [X] Male
  • [] Female
  Date of Birth:
  04/AUG/1995
  
  Address:
  2362 Bridge Street - Floor 3, Room 1
  
  ZIP / Postal Code:
  2362
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [] Mobile
  • [] Home
  • [X] Work
  • [] Other
  Phone Number:
  7716389
  
  Email:
  (( Allerion ))
  

III. RELEASE INFORMATION

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

• Format of Medical Information Release:
  • [X] 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: 02/JAN/2023
  • To: 02/JAN/2023

• 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)
  • [X] 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, [write your full name here], 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, Eric Contreras, 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, Eric Contreras, 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, Eric Contreras, 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, Eric Contreras, 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:
  E. Contreras
  
  Date:
  02/JAN/2023

[Kaden Malik]

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Dear Mr. Eric Contreras

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 $10,000 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