[RELEASE REQUEST] NEO TRUDGILL

[Neo Trudgill]

I. PATIENT INFORMATION

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• Title: (select one)
  • [] Mr.
  • [] Mrs.
  • X[] Ms.
  • [] Other
  First Name:
  neo
  
  Middle Name: (optional)
  
  
  Last Name:
  trudgill
  
  Gender: (select one)
  • [x] Male
  • [] Female
  Date of Birth:
  31/1/90
  
  Address:
  Sunshine Apartments 1 1
  
  ZIP / Postal Code:
  83847A
  

II. CONTACT INFORMATION

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• Phone Type: (select one)
  • [x] Mobile
  • [] Home
  • [] Work
  • [] Other
  Phone Number:
  4411
  
  Email:
  [email protected] (( BarbieXL ))
  

III. RELEASE INFORMATION

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• Purpose of Medical Information Release:
  • [] Further Treatment / Continued Care
  • [] Personal Use
  • [x] 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: 12/2/24
  • To: 13/2/24

• 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)
  • [] 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, [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, neo trudgill, 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, neo trudgill, 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, neo trudgill, 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,neo trudgill, 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:
  neo trudgill
  
  Date:
  13/2/24

[Neo Trudgill]

((I had to rewrite it and post it quickly because it logged me off the first time and had to write it again, so i first posted the layout and edited it afterwards, maybe an option on the site so it doesn't log you off too quickly))

[Kaden Malik]

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Dear Neo Trudgill,

We appreciate your recent request for your medical records, and we have diligently conducted a search within our healthcare facility's records system.

However, after a thorough review, we regret to inform you that we were unable to locate any documentation indicating that you were diagnosed with a specific medical condition at our hospital. It is possible that you received a diagnosis or treatment at another healthcare institution.

To access your complete medical history, including any diagnoses and treatments you might be seeking, we recommend contacting the hospital or medical facility where you believe these records may be held. They should be able to assist you with obtaining the necessary documentation to fulfill your request.

If you require any assistance or have further questions regarding this matter, please do not hesitate to reach out to our administrative team, and we will be happy to provide any additional support we can.

Thank you for choosing our healthcare facility for your medical needs. We wish you the best of health and are here to assist you in any way we can.

Kind regards,
Kaden Malik, M.Sc.
Medical Administrative Department
Pillbox Hill Medical Center