Fillable The Washington Endocrine Clinic Medical Records Release Form (Page 2 of 2) in pdf

Michael J. West, M.D., Ph.D.

Board Certiﬁed in Endocrinology, Diabetes and Metabolism

Treyce S. Knee, M.D.

Board Certiﬁed in Endocrinology, Diabetes and Metabolism

Donna Westervelt, MS, CRNP, CDE

Diabetologist

Tammy Peng, RD, LD

Registered Dietitian

Speciﬁc records to be released:

HIPAA laws allow the Clinic to include in a “medical record request” records that the providers at the Clinic used to

make decisions about patients. These can include such additional items as medical records brought/sent to the Clinic

by a patient from other healthcare providers, billing records, and/or registration papers. Many patients have found that

they do not need all of these records as they have kept a copy of records provided to the Clinic from other healthcare

providers, and have received insurance billing records directly from their speciﬁc insurance company. (Patients who

want insurance EOBs should contact their speciﬁc insurance company for a copy of these EOBs).

I only want released the registration papers, medical notes from each visit, labs, radiology, and/or pathology

reports that were ordered by providers at the Clinic.

(for patients with diabetes) Also include all diabetic insulin pump downloaded reports, glucometer download

reports, and personal glucose logs.

Also include all medical records in my ﬁle from outside healthcare providers.

Also include all billing records (does not include insurance EOBs).

HIV/AIDS: I DO ! DO NOT ! consent to the release of any positive or negative test result for AIDS or HIV infection,

antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my medical records.

Initial: ______________ Date: ______________________________

By signing this form, I authorize the Washington Endocrine Clinic to release protected health information (PHI) to the

person(s) or entity listed above.

Patient Signature: _______________________________________

Date _____________________

Method of Payment:

The Clinic accepts payment for this medical record request in the form of a credit card, debit card or cash.

Checks are not accepted. If you are paying by credit card, you must provide the following for this form to be

processed: Credit Card # ___________________________________ Exp date _________ CCV# _______

Street number or house number of credit card billing statement: ___________________.

For example, if you live at 9925 Main St, City, State, USA 12345, please write in the space above “9925”.

Zip code of the credit card billing statement: ___________________

For example, if you live at 9925 Main St, Anywhere, USA 12345, please write in the space above “12345”.

2440 M Street, NW ▪ Suite 417 ▪ Washington, D.C. 20037

Phone 202-570-5151 ▪ Fax 202-446-2946

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The Washington Endocrine Clinic Medical Records Release Form Page 2