Long Beach Clinical Trials

Long Beach - HIPAA Release Medical Record Request


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 Clinical Trials (LBCR). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from LBCR, a signed authorization form must be received. Without your authorization, LBCR will not release any information.

MUST SELECT AT LEAST ONE OPTION

  Release

 

Long Beach CLINICAL Trials RELEASE

Long Beach Trials
It may be important for LBCR 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 LBCR 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

LBCR Release

Proprietary and Confidential | Version 1.0 (1AUG2014)

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Long Beach Clinical Trials http://longbeachclinicaltrials.com
Signature Certificate
Document name: Long Beach - HIPAA Release Medical Record Request
Unique Document ID: 32ba827777ebc93b68eb937f1d5a6f9260bac7e4
Timestamp Audit
2016-06-08 15:22:10 PDTLong Beach - HIPAA Release Medical Record Request Uploaded by Long Beach Clinical Trial - recruiter@longbeachclinicaltrials.com IP 104.182.58.26