medical records requests Step 1 of 2 50% Request for Medical RecordsProvider requesting medical/health/billing records:*Assume Patient Care as (PCP)Follow patient jointlySend my medical recordsPatient request own medical recordsToday's date* Date Format: MM slash DD slash YYYY Full Name*Date of Birth* Date Format: MM slash DD slash YYYY Phone:*Secondary Phone:Work Phone:Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code The next few questions pertaining to where we should request records from (hospital, clinic, or Dr. Office/s name and numbers)Name of facility and doctor/s who provided services to you:*Facility Phone*Facility Fax*Reason for Request*LabsX-RayPathologyCulturesMedications and ImmunizationsOffice VisitERHospital Admit and DischargeOperative ReportH&PCardiac StudiesPulmonary FunctionSleep StudyBillingMinidoka Medical Center RHC 1308 8th Street Suite 1 Rupert, Idaho 83350 Office: (208) 436-4322 Fax: (208) 436-1312 Email: firstname.lastname@example.org (not a secure email, you MUST send an encrypted file)Are you the patient? Or are you a parent or personal representative signing for the patient?*PatientRepresentative / ParentPatient Signature*Representative Name*Date of Birth* Date Format: MM slash DD slash YYYY Phone*Relationship to patient:*Is your address different from the patient's?*YesNoRepresentative's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Representative's Signature* Patient Rights and ResponsibilitiesWHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RESPONSIBILITY TO: Treat the staff with consideration, respect and dignity. Understand that your life-style does affect your health. Take an active part in your health care. Follow the agreed upon treatment plan. If you choose or are unable to follow the treatment plan, it is your responsibility to inform the Medical Provider. Observe facility rules and regulations that are for the safety and consideration of all patients and staff. Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives (living wills or durable power of attorney), and other matters relating to your healthcare. Report whether you understand a contemplated course of action and what is expected of you. WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RIGHT TO: Be treated with consideration, respect and dignity; Have the confidentiality of your medical information protected, to have privacy act regulations enforced, and to have these areas of confidentiality explained to you in language you can understand; Have privacy during case discussion, counseling & treatment; Review your records in the presence of a healthcare professional; Know the name and qualifications of staff providing your care; Know your diagnosis, health problems, test results, the potential advantages and risks of treatment or procedures in language you can understand; Expect that all services, treatment and counseling techniques will take place with your informed consent; Participate in referral planning; Have access to the patient comment procedure; Refuse to participate in research. Have another individual present in the exam room with you, if you so desire. I have read the copy of Patients Rights and Responsibilities* I agree Release of information, treatment, privacy rights, and messagesConsent for Photograph* I consent to allow photography of myself for identification purposes, and for purposes of improving my medical care documentation (ie: wounds, lesions, etc).. Authorization for Treatment* I hereby authorize, Minidoka Medical Center, and any assistants or associates that may be designated, to perform medical and hospital care to the above named patient Privacy Practices / Discrimination* I have received/or declined copy of the Notice of Privacy Practices, and I have been provided an opportunity to review this entire document. Minidoka Memorial Hospital and Medical Center will not discriminate against a patient because of race, color, national origin, religion, ability to pay, or because a patient is covered by a program such as Medicaid or Medicare. If you feel you are a victim of discrimination you have the right to file written complaint to the Compliance Officer. Forms are available in the business office. Consent to use of answering machine and/or voicemail messaging/email:* I hereby consent to the use of my answering machine and/or voicemail for the purpose of relaying important information regarding my treatment or care, including, but no limited to confirmation of appointments, changes in medication, results of lab tests, special instructions for testing procedures. I also consent to members of my family receiving this information in my absence. This consent will remain in effect until I rescind the consent in writing. SignaturePhone*Today's Date* Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.