Long Beach - HIPAA Release Medical Record Request-B

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 Long Beach Research (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

Release

I DO authorize LBRI to release all study related records to the physician above.

I DO NOT authorize LBRI to release any study related records to the physician above.

LONG BEACH CLINICAL RESEARCH RELEASE

Long Beach Research
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.