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Get AZ DoctorCare Medical Records Release Form 2008-2024
PO Box 7904 Cave Creek, AZ 85327 Office Hours: Mon-Thurs: 9am-4pm (closed 12pm-1pm) Fri: 9am-12pm Phone: 480-575-0576 Fax: 480-575-0512 www.doctorcareaz.com Medical Records Release Form Patient Name.
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Fri FAQ
THINGS YOU MIGHT NEED TO KNOW: Full and legal name. Home address. Date of birth. Emergency contact information. Phone number and email address. Preferred method of contact. Changes in marital or job status.
This includes the medical record, billing records, and any other information that is used to make decisions about the patient.
A. Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider.
A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed. An expiration date or expiration event when consent to use/disclose the information is withdrawn.
Elements: A description of the PHI. The name of the person making the authorization. The name of the person or organization who is authorized to receive the PHI. A description of the purpose for the use or disclosure. An expiration date for the authorization. The signature of the person making the authorization.
Arizona state law requires that a physician must make medical records available when a patient submits a request in writing. Patients often sign a release form, but a written request is the best way to communicate a medical records request to your health care provider.
Elements of a release form Patient information. Naturally, the release should require the patient's information so it's clear who the form refers to. ... Receiving party's information. ... Information to be shared. ... Purpose of the release. ... Expiration of authorization. ... Disclaimers. ... Date and signature.
I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.]
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