HIPAA Release Medical Record Request
INFORMATION TO BE RELEASED FROM
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.
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.
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.
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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Document Name: HIPAA Release Medical Record Request
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