Hippa-Release


Chandler Clinical Trials-HIPAA Release Medical Record Request

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 Chandler Clinical Trials (CCT). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from CCT, a signed authorization form must be received. Without your authorization, CCT will not release any information.

MUST SELECT AT LEAST ONE OPTION


Chandler CLINICAL TRIALS RELEASE

Chandler Clinical Trials
It may be important for CCT 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 CCT 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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Signature Certificate
Document name: Hippa-Release
lock iconUnique Document ID: 0aa66c006146e047aa44916e0a4847b6fd2e6c9b
Timestamp Audit
July 27, 2022 6:06 am GMTHippa-Release Uploaded by Ron Lerner - [email protected] IP 73.24.222.43