Attach a copy of patient's ID (.jpg, .pdf, .doc, .docx – less than 10 MB in size):

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REQUEST MEDICAL RECORDS

Medical Record Privacy Conditions

You must agree to the following conditions to request the Medical Records. The below form is applicable to INPATIENT admission only. Click on one of the three topics below for more information:

Introduction

Medical records are considered highly confidential because of the very private, personal information they contain. You have the right to access your own
medical information and can control who else is able to access it. With some exceptions, health care providers will release a copy to you and your authorize representative.

To receive copies of a patient’s medical record, the patient must first sign a release of information letter to the hospital, and also attach a copy of the patient's passport as proof of identity.

You have the right to request of your dependents (e.g. children) if they have not yet reached the age of 18. You can do this by providing the hospital with a copy of the guardian's passport as well as the authorization letter, and submitting it with a copy of the child's birth certificate. 

Medical Records Information

-Medical certificate (please specify visit and purpose)
-Other medical forms (please specify visit and doctor name) 
-Copy of medical record (please specify visit and purpose)

Authorized Documents Needed

-In the case where you are requesting the medical record by yourself, on the day you pick up the records, we must be given a copy of your ID/passport. If you are requesting us to send via post, fax of email, you will need to provide us with a copy of your ID/passport, as well as the fax number or email address where the records should be sent.


-In the case where a patient agrees to release the medical record to an agent/representative, this agent/representative must provide us a copy of the patient's ID/passport and authorization letter. The letter must state that you are an authorized representative, state that Clemenceau Medical Center should release these medical records to this authorized representative, and have the patient’s signature, along with the date the document was signed.

I am requesting these medical records for:

Myself *

Other *

I agree to conditions of medical record request listed above

I do not agree

The medical records request form will appear after you have selected “I agree” above

Title*

Patient first name *

Patient last name *

Date of birth *

MRN *

Street Address *

City *

Phone *

Email *

Medical Record Details:

Completed insurance

Insurance file

Copy of medical records for visit dates

From

To

Paper

CD / DVD

How would you like to receive the medical records :

Pick up at Clemenceau Medical Center (Please bring patient's ID/passport and authorization letter)

Mailing address

Tel.

Fax number

E-mail address

Other

If you are not picking up the medical records in person, you must upload the following files:

Attach a copy of patient's ID (.jpg, .pdf, .doc, .docx – less than 10 MB in size):