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Recipient: Information to be released to: Dr. Robert Morin, Quality Research Inc.

 

303 W. Sunset Road #102

San Antonio, TX 78209

(210) 824-5678

 

Fax: (210) 824-9829 

 

Revocation: I understand that I may revoke this consent at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to Health Information Services Department. I understand the revocation will not apply to information that has already been released in response to this authorization. This consent will automatically expire twelve months from the date of my signature. I do not authorize further release to a third party. I understand that once information is released under this authorization, clinic and their employees and my physician(s) cannot prevent the re-disclosure of that information.

 

Expiration: One year from date of request

 

Authorization: I authorize the above provider to release the information marked above to the recipient, 

 

 

 

These forms are provided as a sample to subscribers to HIPAAps.com, Inc., and do not constitute legal advice. All forms should be reviewed by competent counsel to ensure that they apply correctly to the laws and regulations in your locale. 

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First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Additional Information

Social Security # *
YOUR Clinic: Information to be released from:

CLINIC and PHYSICIAN Name *

Address *

State *

Zip code *

Phone # *

Fax #
Date of Service Requested: PAST 2 YEARS ONLY
Clinic Visit / Progress Notes, Consultation/Follow-up Reports, Special Tests, Lab Reports, X-Ray Report/Mammography Report, HIV/AIDS, alcohol, drug treatment, psychiatric/psychological treatment, and/or records relating to communicable disease and/or those marked confidential. *Information in your chart that was not originally generated by this clinic will not be released to another facility. Such information must be obtained from the original source.
Hospital Reports:
Hospital Admission & Discharge Summary:
Reason for Release:

Clinical Study Participation: (indicate Protocol # and condition being studied) Leave blank if not known
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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