Acclaim Clinical Research

HIPAA Release Medical Record Request


 

 

INFORMATION TO BE RELEASED FROM

Phone: 

PRIMARY CARE PHYSICIAN RELEASE

It may be important for your physician to receive records from Acclaim Clinical Research (ACR). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from ACR, a signed authorization form must be received. Without your authorization, ACR will not release any information.

MUST SELECT AT LEAST ONE OPTION

  Release

 

ACCLAIM CLINICAL RESEARCH RELEASE

It may be important for ACR to contact your physician and/or receive medical records from your physician in order for us to determine your eligibility for the study. In order for ACR to contact or receive medical records from your physician, a sign authorization form must be completed. Without your authorization, we will not contact or request medical records from your physician.

MUST SELECT AT LEAST ONE OPTION

ACR Release

I authorize the release of my STD results, HIV/AIDS, ALCOHOL/SUBSTANCE ABUSE testing, as defined by law, RCW 70.24 et seq., whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.
 

PLEASE READ CAREFULLY

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED, AND CAN BE REVOKED IN WRITING AT ANY TIME. I UNDERSTAND I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION AND THAT ANY REFUSAL TO SIGN IT WILL NOT AFFECT MY ENROLLMENT IN A HEALTH PLAN OR ELIGIBILITY FOR HEALTH BENEFITS.

The undersigned hereby authorizes the release of their medical records and/or demographic information including their name, address and phone number to ACR and their affiliates as it pertains to any/all clinical research studies. All information provided will remain with ACR and its affiliates. A photocopy of this authorization shall be the same authority as the original.

Proprietary and Confidential | Version 3.0 (19OCT2018)

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Signature Certificate
Document name: HIPAA Release Medical Record Request
lock iconUnique Document ID: c510271af37708e484053980b1c45e4e2d9e82df
Timestamp Audit
December 3, 2021 9:57 am PDTHIPAA Release Medical Record Request Uploaded by Kun Chap - kchap@acclaimclinicalresearch.com IP 76.214.69.88, 127.0.0.1, 184.168.224.71, 0.0.0.0, 76.214.69.88