Request to have outside medical records or imaging studies sent to ReviveMD

Patient Information:

Patient First Name

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Patient Last Name

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Date of Birth

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Any other Previous Names

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Patient Address

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Phone #

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City

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State

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Zip

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I hereby authorize Prima CARE to RELEASE my medical record information to:

Name/Facility

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Attention

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Address

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Phone #

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City

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State

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Zip

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Fax #

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Purpose of Request

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Other

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Specific imaging studies or reports from

Name of Institution

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Send a 2-year abstract of my records to ReviveMD

Previous diagnostic test reports and/or imaging films or discs: X-ray, CT, MRI, pathology, labs, etc

Other – be specific, include dates and MD’s under comments.

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Restricted authorization to release Protected Health Information:

IMPORTANT – It is extremely important that you select either you “DO” or “DO NOT” for each item contained in this section. Please do not skip any line item as it could delay the fulfillment of your request.

want Mental/Behavior Health or Disability Services Provider Documentation * released

Please select an option.

want HIV/AIDS Screening Test Results released

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want information about Alcohol and/or Substance Abuse Treatment released.

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want Genetic Testing/Test Results ** released.

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want Confidential Communications with a Social Worker released

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want information about Rape/Sexual Assault Victim’s Counseling released.

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want Child/Elder Abuse or Neglect & Abuse of an Adult with a Disability released.

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want information about Sexually Transmitted Disease (STD’s) released.

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want information about Abortion released.

Please select an option.

* This Authorization is not valid for use or disclosure of psychotherapy notes.
** The term “genetic tests” means only those tests which determine your future chances of developing a disease, not test done to diagnose a current condition

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

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Signature of Personal Representative

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Relationship to patient or authority to act for patient

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Date

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