Request to Access Medical Record
Washington Regional Medical Records
Mailing Address: 3215 N. Northhills Blvd., Fayetteville, AR 72703
Physical Address: 3318 N. Northhills Blvd., Ste. 110, Fayetteville, AR 72703
Phone: 479.463.1158
Request to Access Medical Record
Please fax completed form to Washington Regional Medical Records at 479.463.1239
Patient Name:__________________________________________________________________________________
Birth Date:___________ Last 4 digits of your SSN:_________________ Phone:______________ Home/Cell/Work
Street Address:____________________________________City:_______________State:_________Zip:_________
Please Check the Types of Records to Be Accessed:
__Complete Medical Record
___Consultation
__Discharge Summary
___Pathology Report
__Operative report
___EKG
__History and Physical
___ER Record
__Other, Please Specify __________________________________
___Radiology Reports ___Laboratory Tests ___X-rays ___Billing
Dates of Service:
__ All dates of service __ Date of Service From ____________________ To _________________________
Delivery of Records:
I request that a copy of my records be delivered to me by the following method:
__ In person pick-up
__ Mail to _______________________________________________________
Name of person to whom the records are directed
____________________________________________________________________________________
Street Address
City
State ZIP
__ Fax to _____________________________________________
__ Secure Email to _______________________________________
__ Other _____________________________________________________________________________________
I understand that I am allowed to have access to these records and that, where readily producible, the information will be provided to me in the form and format of my request. I understand that my request must be made in writing and that it may be denied in certain limited circumstances.
I understand that my request will be acted upon within 30 days unless I'm given written notification informing me that an extension of up to 30 days is needed.
I understand that Washington Regional Medical Center cannot be responsible for the security of my records once delivered according to my direction.
Updated 7/6/22
Page 1 of 2
I understand that personal health information should not be sent via email in an unencrypted file and, although it is my right to request such delivery, I understand that Washington Regional Medical Center strongly suggests that I choose an alternate delivery method.
I understand that I will not be charged for this request.
__________________________________________________ Signature of Patient
__________________ Date
If you are acting as a legally authorized representative of the Patient, please complete the section below.
___________________________________________________ Printed Name of Representative
___________________________________________________ Signature of Representative
__________________________________ Relationship to Patient (parent, legal guardian, etc.)
__________________________________ Date
Updated 7/6/22
Page 2 of 2
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- access medical center
- how to access medical center benefits university of virginia
- how to access medical center benefits self service for annual enrollment
- remote work step by step guide computers boston medical center
- job application access medical centers
- patient s request for access to protected health information
- request to access medical record
- north bend medical center inc
- access services applying for access
- access medical center privacy and billing procedures nextcare
Related searches
- free printable medical record forms
- cms medical record documentation guidelines
- florida hospital medical record request
- medical record documentation best practice
- medical record abbreviations and symbols
- importance of medical record documentation
- medical record documentation guidelines
- medical record attestation
- medical record signature attestation
- medical record attestation statement
- state of ct medical record retention
- cms medical record retention guidelines