Billing Statement For Copies Of Medical Records printable pdf download

Billing Statement For Copies Of Medical Records

BILLING STATEMENT for COPIES of MEDICAL RECORDS

Name of Patient:

Medical Record Number (MRN)

Address where information can be sent:

Thank you for contacting us for a copy of your medical record. We value you as a patient and appreciate the

opportunity to service your Release of Information medical record request.

As you may know, we are governed by the Health Insurance Portability and Accountability Act of 1996

(HIPAA) to protect patients’ rights to confidentiality as well as to track and report each request.

Therefore, in order to fulfill your request, we must ask for an upfront fee. This fee will offset the cost associated

with copying, tracking, and reporting processes surrounding your request. Please indicate on the Request Form

what medical records are to be copied and sent to the intended recipient. Please attach this form to the formal

Medical Record Request and Authorization. This document will not replace the request or authorization.

Please include a check in the amount of $25.00, payable to BACTES, or fill out the credit card

information below and return this form to us for processing. We will process your request when payment

has been received. Please do not pay with cash.

Type of Credit Card (Visa, MC, or AMEX):

Credit Card Number:

Security Code:

Expiration Date:

Name on Card:

Billing Address:

Telephone: (

)

Requestor Signature:

Billing Statement For Copies Of Medical Records