Fillable Patient Request to Access Records For Self or

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Patient Request to Access Records For Self or

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The Patient Request to Access Records For Self or form is 1 page long and contains:

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  • 42 check-boxes
  • 26 other fields

Country of origin: OTHERS
File type: PDF

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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-deciency
syndrome (AIDS) or human immune-deciency 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 Holmes Regional Medical Center Health First’s Palm Bay Hospital
Health First’s Viera Hospital MSDS MGIC _____________________________________________
Abstract (summary) Cardiology Test results (Labs) Entire record
Emergency Department record Progress notes Radiology, X-Ray reports
History and Physical Physician orders Images, lms
Discharge summary Operative/Procedure report Other___________________________________________
H
ealth First Medical Group/Clinic Records
Provider(s) Name___________________________________________________________
Ofce 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_______________________________________
(Photo ID required for pick up)
Electronic copy: CD 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 le, records will be mailed.
Patient’s/Legal Representative’s Signature ____________________________________________________Date ______________
Legal Representative’s Printed Name ______________________________________Relationship to Patient __________________
07282020
HF.org
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 veried and processed by: Universal ID _________________________ Date_________________
Request for access/disclosure has been: Granted Partially Granted Denied
Form of ID presented for verication: Driver’s License Government ID Other (specify)_________________________
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Patient Request to Access Records For Self or

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Completed 4 May 2022

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