Hippa Release


Long Beach Research Institute-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 Long Beach Research Institute (LBRI). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from LBRI, a signed authorization form must be received. Without your authorization, LBRI will not release any information.

MUST SELECT AT LEAST ONE OPTION


Long Beach Research Institute RELEASE

Long Beach Research Institute
It may be important for LBRI 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 LBRI 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



 

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Hippa Release
lock iconUnique Document ID: 537b1963b3e60080939ff5215db19100d3cda8a0
Timestamp Audit
05/28/2025 4:48 pm MSTHippa Release Uploaded by Yelena Quintanilla - yquintanilla@longbeachresearch.com IP 107.2.58.213