ADVANCED ORTHOPEDICS & SPORTS MEDICINE, P.A.
2300 N 14th Ave., Suite 104, Dodge City, KS 67801
Privacy Official: Jennifer King
PHONE NUMBER: 620-225-7744
FAX NUMBER: 620-225-5522
Request for Access to Records
Notice to Patiebt: You may use this form to request to inspect or copy information maintained about you.
This type of request is described in our Practice's Notice of Privacy Practices.
Patient Name: ___________________________________________________________________
I authorize ____________________________________ to release healthcare information concerning the above name patient to:
Name: ________________________________________
Address: ______________________________________
Phone: ________________________________________
Fax: __________________________________________
Description of Records Requested:
(Please describe the records or types of records requested. Please also let us know how far back in time you want access to records.)
| TEST RESULTS |
_______________ |
PROGRESS NOTES |
_______________ |
| BILLING RECORDS |
_______________ |
X-RAY/MRI REPORTS |
_______________ |
| OTHER |
_______________ |
ENTIRE RECORD |
_______________ |
| ______________________________________________________ |
Contact Person
Please contact our Practice's Privacy Official if you have any questions relating to requests to inspect or copy records. Jennifer King, 620-225-7744.
Patient Information and Authorization
|
Signature of Patient
|
__________________________________________________________ |
|
|
__________________________________________________________ |
|
Date:
|
__________________________________________________________ |
|
Date of Birth (for
|
|
|
identification purposes:
|
____________________________________________________________ |
| I hereby certify that I have the legal authority under applicable law to make this request on behalf of the patient identified above. |
|
|
|
|
Representative,
|
|
|
Relationship (parent,
|
|
|
guardian, POA, etc.:
|
____________________________________________________________ |
|
Date:
|
____________________________________________________________ |
|
Print Name of Personal Rep
|
____________________________________________________________ |
|