Patient Access Request Form

Patient's Full Name *

First

Last

Birthdate

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Date of Incident/Service

What records do you want?

How would you like your records delivered?

Fax Number

Unsecured Email *

* Warning: Records will be sent through unencrypted fax/email that is not secure and there is a risk that the records could be seen by a third party during electronic transmission, while in electronic storage, and/or upon completed delivery. ADCOM is not responsible for unauthorized access of the Protected Health Information resulting from the faxed or emailed transmission, or for safeguarding the Protected Health Information upon delivery. By signing this form, you understand the risks and authorize this method of transmission.

SIGNATURE: I understand that authorization for the disclosure of these records and Protected Health Information is voluntary and I can refuse to sign this authorization. I understand that medical treatment, payment, enrollment, and eligibility for benefits cannot be, and are not, conditioned on whether I sign this authorization. Photocopies of this authorization may be used in lieu of the original. By typing your name below you signify your typed signature is to the same extent as if you had signed this document in ink. *

Printed Name of Legal Representative if Patient is Not Capable of Signing

If this form is not signed by patient, identify relationship to patient. If Legal Representative or other, provide documentation establishing authority such as Power of Attorney.

Signature of Patient or Legal Representative

Signature Date *

YTD Total