WP E-Signature by Approve Me - Sign Documents Using WordPress -

HIPAA Release Medical Record Request

INFORMATION TO BE RELEASED FROM

Phone:

PRIMARY CARE PHYSICIAN RELEASE

It may be important for your physician to receive records from Zenos Clinical Research (ZCR). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from ZCR, a signed authorization form must be received. Without your authorization, ZCR will not release any information.

MUST SELECT AT LEAST ONE OPTION

PCP Release

I DO authorize ZCR to release all study related records to the physician above.

I DO NOT authorize ZCR to release any study related records to the physician above.

I DO NOT have a Primary Care Physician.

ZENOS CLINICAL RESEARCH RELEASE

It may be important for ZCR to contact your physician and/or Medical Center to receive medical records from your physician and/or Medical Center in order for us to determine your eligibility for the study. For ZCR to contact or receive medical records from your physician and/or Medical Center, a sign authorization form must be completed. Without your authorization, we will not contact or request medical records from your physician and/or Medical Center.

MUST SELECT AT LEAST ONE OPTION

ZCR Release

I DO authorize my personal physician and/or Medical Center to provide my medical records to ZCR.

I DO NOT authorize my personal physician and/or Medical Center to provide my medical records to ZCR.

I DO NOT have a Primary Care Physician and/or Medical Center.

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.

Yes

PLEASE READ CAREFULLY

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 demographics information including their name, address and phone number to ZCR and their affiliates as it pertains to any/all clinical research studies. All information provided will remain with ZCR and its affiliates. A photocopy of this authorization shall be the same authority as the original.

Proprietary and Confidential | Version 4.0 (27MAR2023)

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

December 9, 2021 1:26 pm CDT

HIPAA Release Medical Record Request Uploaded by Tony Louis - [email protected] IP 76.214.69.88

May 25, 2023 12:19 pm CDT

Zenos Recruitment - [email protected] added by Tony Louis - [email protected] as a CC'd Recipient Ip: 76.214.69.88