Patient Request to Access Records - Brevard Florida Health ...
Patient Request to Access Records
For Self or Designated Third Party
Patient Information
Patient Name ________________________________________________________________ Today's Date_______________________
Patient Phone_________________________________________________________ Date of Birth______________________________
Last 4 digits of SSN __________ Medical Record Number________________________
I am requesting that Health First: For myself: -OR-
To be sent to third party (specify address below):
Name_________________________________________________________________________________________________________
Address________________________________________________________________________________________________________
City ______________________________________________________________ State___________ Zip__________________________
Phone ________________________________Fax____________________________________
I understand that my health record may include information relating to sexually transmitted disease, acquired immune-deficiency syndrome (AIDS) or human immune-deficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
Information Requested (Fees may apply) (Check all that apply)
Treatment Dates Requested______________________________________
Hospital/Outpatient Records Health First's Cape Canaveral Hospital Health First's Viera Hospital MSDS
Health First's Holmes Regional Medical Center Health First's Palm Bay Hospital MGIC _____________________________________________
Abstract (summary) Emergency Department record History and Physical Discharge summary
Cardiology Progress notes Physician orders Operative/Procedure report
Test results (Labs)
Entire record
Radiology, X-Ray reports
Images, films
Other___________________________________________
Health First Medical Group/Clinic Records
Provider(s) Name___________________________________________________________
Office visit
Laboratory report
Physical exam
Procedure report
Radiology report
Entire record
Other__________________________________________
How would you like your records delivered?
Paper copy: Mail Fax For pickup by designated person, name_______________________________________
_
Electronic copy: CD
(Photo ID required for pick up)
Email (secure)*: ________________________________________________________________
*Email is not a secure means of communication. I acknowledge that if I choose to receive my records via electronic means, the information will be encrypted. If a single transmission cannot accommodate size of the file, records will be mailed.
Patient's/Legal Representative's Signature ____________________________________________________Date_______________
Legal Representative's Printed Name ______________________________________Relationship to Patient___________________
Main Health Information Management Department Locations:
Health First's Holmes Regional Medical Center 1350 S. Hickory St., Melbourne, FL 32901
Phone 321.434.3288 | Fax 321.434.5027
Health First Medical Group (HFMG) 730 Malabar Road., Malabar, FL 32950 Phone 321.549.0695 | Fax 321.724.8069
FOR OFFICE USE ONLY: Request verified and processed by: Universal ID _________________________ Date_________________
Request for access/disclosure has been:
Granted
Partially Granted
Denied
Form of ID presented for verification: Driver's License Government ID Other (specify)_________________________
07282020
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