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HIPAA Release Medical Record Request

INFORMATION TO BE RELEASED FROM

PRIMARY CARE PHYSICIAN RELEASE Primary Care Physician It may be important for your physician to receive records from San Jose Clinical Trials (SCT). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from SCT, a signed authorization form must be received. Without your authorization, SCT will not release any information.

MUST SELECT AT LEAST ONE OPTION

SAN JOSE CLINICAL TRIALS RELEASE San Jose Clinical Trials It may be important for PCT to contact your physician and/or receive medical records from your physician in order for us to determine your eligibility for the study. In order for SCT to contact or receive medical records from your physician, a sign authorization form must be completed. Without your authorization, we will not contact or request medical records from your physician.

MUST SELECT AT LEAST ONE OPTION

MCR Release

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September 28, 2023 7:48 am PDT

HIPAA Release Medical Record Request Uploaded by Sara Viznyuk - [email protected] IP 73.15.82.230