ADVA Clinical Research

ADVA - HIPAA Release Medical Record Request


HIPAA Release Medical Record Request

 

 

INFORMATION TO BE RELEASED FROM

Phone: 

PRIMARY CARE PHYSICIAN RELEASE

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

MUST SELECT AT LEAST ONE OPTION

  Release

 

ADVA CLINICAL RESEARCH RELEASE

ADVA Clinical Research
It may be important for ADVA Clinical Research 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 ADVA Clinical Research 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

ADVA Clinical Research Release

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.

PLEASE READ CAREFULLY

The undersigned hereby authorizes the release of their medical records and/or demographics information including their name, address and phone number to ADVA Clinical Research and their affiliates as it pertains to any/all clinical research studies. All information provided will remain with ADVA Clinical Research and its affiliates. A photocopy of this authorization shall be the same authority as the original.

Proprietary and Confidential | Version 3.0 (01NOV2018)

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ADVA Clinical Research http://advaclinicalresearch.com
Signature Certificate
Document name: ADVA - HIPAA Release Medical Record Request
Unique Document ID: a702cbe3b6139e9d12214623e56ed195db539fab
Timestamp Audit
August 22, 2019 12:18 pm PSTADVA - HIPAA Release Medical Record Request Uploaded by Irving Sanchez - irving@navazondigital.com IP 98.152.154.117