Patient Request for Health Information
Patient Information (Please Print) First Name:
Middle Initial.
Last Name: Harper
Alex
Name at Time ofTreatment (if different than above): Date ofBirth (MM/DD/YYYY):
, Pho l!. e: Enter Exercise# as area codeE-mail (optional):
08/08/1965 Street Address:
En�_er 7-digit AHIMA ID
City:
I Zip:
I State: PA
Waterton
18655
10504 Stoney Brook Lane
What records do you want'? (Check appropriate boxes below): Date(s) of Service:�/ �;2007 through�/ �;2007 0Discharge Summary 0Emergency Room Records □ operative/Procedure Reports □ Billing Records 0Test Results (X-Rays, Lab/Pathology Results) Please specify· ___________________ Oother (Immunization Records, Medication Lists) Please specify: _________________ _ How would you like your records delive1·ed'? 0Paper 0Home Delivery 0Tn-Person Pickup □ Electronic (Email, USB, CD, Portal, Other) Please specify· ______________ W ere do vou want the information sent? (Fill in boxes below): · , �["!U f1�P should provide my records to: 0Self D Personal Representative (indicated below) Recipient Name� Recipient Phone: Alex Harper Recipient Fax: Recipient Mailing Address: Recipient E-mail (if applicable): 10504 Stoney Brook Lane AHarper@ameritech.net
Please print your name and sign below:
IQ Ill/(
Date/Time
PI ease return comp1e e orm o: I t d f t
E-mail: AHIMA Medical Center - HIM Department 123 Record:: Fax: (312) 221-1801 Questions? AHIMA Medical Center
recognizes a patient's right under HJPAA to access copies of his/her health information.
There may he charges associated with pmcessi11g a request and pmduci11g requesred recnrds. �,;-�R... Number of Pages: Two Chart Location: ··
7,�; i,. II �fJL./ Y�s
Delivery Method: Mail
Main Reason for Request: Continuing Care
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