Authorization to release medical records Authorization Request for Access to Health Information Name of Patient:(Required) First Last Previous Name: Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth:(Required) MM slash DD slash YYYY 1. I am requesting from Doctor’s Choice Home Care (“DCHC”) to:(Required) inspect obtain a copy of the following health information that is maintained in a designated record set by DCHC: Health Information(Required) Complete home health medical record with Plan of Care/Orders Hospital/SNF/Other Facility discharge records Treatment Notes Billing/Invoice Other health information: Complete home health medical record Date(s) of Service:Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Hospital/SNF/Other Facility discharge records Treatment Notes Date(s) of Service:Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Billing/Invoice Date(s) of Service:Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Other health information Date(s) of Service:Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Please Specify Other Health Information: 2. I am requesting that DCHC send a copy of my records in the following format. I understand that DCHC will provide access to my records in the form and format that I request only if DCHC determines that it is readily producible in such form or format.(Required) Paper. If the preferred format is not readily producible, the access will be provided in a readable hard copy form or other such agreed upon form. Electronic. If the preferred electronic format is not available in a readily producible by DCHC, DCHC will make the information available in an agreed upon alternative, readable electronic format. Electronic Format: Word PDF Excel Other (USB, CD, Other): Please Specify Other Electronic Format: 3. I am requesting DCHC to send my records in the following manner. I understand that DCHC will use best efforts to deliver records in the manner that I request.(Required) Email (Encrypted): In an effort to protect your health information, our standard practice is to encrypt our email. US Mail: In-Person Pickup Other Email Address: US Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please Specify Other Delivery Method for Records 4. I am requesting that my records (in the above-indicated format) be sent to the following individual:Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneEmail (Only if requesting records to be sent via email)I hereby request DCHC to provide me with access to my health information that DCHC holds about me in the DCHC designated record set in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I understand that DCHC has 30 days to respond to this request and that DCHC may extend this 30-day response period for another 30 days if, within the initial 30-day period, DCHC provides me with a written statement of the reasons for the delay and the date by which it will respond. I understand that in certain circumstances DCHC may deny my request. I also understand that DCHC may charge a reasonable fee associated with copying (including the cost of supplies and labor), postage (if you want the records mailed to you), and, if requested, for preparing a summary or explanation of any records. These fees are described in the Schedule of Charges attached to this form.Signature of Patient/Legal Representative(Required) Reset signature Signature locked. Reset to sign again Today's Date(Required) MM slash DD slash YYYY Print Patient Name /Legal Representative Name(Required) First Last Today's Date(Required) MM slash DD slash YYYY If signed by the patient’s personal representative, explain authority to act on behalf of the patient:CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
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