medical records request.

Professional Physical Therapy patients request your medical records here

AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION

Fill out the below form and we will deliver your medical records in a timely manner within 48-72 hours, for some cases sooner. We always strive to save you time and give you the highest level of customer service available. Utilize this digital form to save time. After completing, our operators are always available to issue refunds or make adjustments if you need.

NOTICE: THIS FORM IS ONLY FOR PATIENT USE.

IF YOU ARE NOT THE PATIENT, PLEASE DO NOT FILL OUT THIS FORM.

STEPS:

1. Fill out the form

2. Pay a flat fee of $6.50 to process and release records

3. Your records are delivered via email.

*As per the HITECH Act Law, for direct access patient requests, the legal cost is a flat fee of $6.50 to release records electronically only.

Patients - Request Medical Records

"*" indicates required fields

Patient First Name*

Patient Last Name*

Patient Email*

Patient Phone*

Patient Date of Birth*

Patient Address*

Street Address Address Line 2 City State ZIP Code

I authorize ProPT to disclose my PHI to:*

Select from dropdown, then enter the information of the place you want records sent to.

Attorney/Law Firm Name*

Attorney/Law Firm Phone*

Attorney/Law Firm Fax

Attorney/Law Firm Email

Attorney/Law Firm Address*

Street Address Address Line 2 City State ZIP Code

Disability Insurance Provider Name*

Disability Insurance CLAIM #

Insurance Phone*

Insurance Fax

Insurance Email

Medical Provider Practice Name*

Medical Provider Doctor Name*

Medical Provider Phone*

Medical Provider Fax

Medical Provider Email

Medical Provider Address

Street Address Address Line 2 City State ZIP Code

Other: Name*

Other: Relationship*

Other: Phone*

Other: Fax

Other: Email*

Professional Occupational and Physical Therapy, PLLC, ProEx Physical Therapy, LLC, StarPro Physical Therapy, in affiliation with Professional Physical Therapy, and all their affiliated entities (collectively, “Provider”) create and maintain information about its patients. This information, which is referred to as “protected health information,” is subject to certain privacy protections that are defined in the Provider’s Notice of Privacy Practices (available to you upon request). By signing this authorization form, you are authorizing Provider to use and disclose your protected health information, as set forth below.

1. I authorize Provider to use and disclose the following protected health information.*

(Check as applicable and provide specific details where indicated):

All treatment and billing records

Treatment records from (date) to (date)

Billing records from (date) to (date)

Other (please specify in detail)

Treatment Records From Date*

Treatment Records To Date*

Billing Records From Date*

Billing Records To Date*

Other: Please specify in detail*

2. A] I authorize Provider to use and disclose my protected health information for the following purpose(s).*

a. Treatment/Consultation

b. Billing/Claims

c. Legal/Attorney

d. Other

2. B] Please specify your selection(s) in detail:*

3. This authorization expires on the following date and/or event*

4. I acknowledge that I have the right to refuse to sign this authorization and Provider may not condition the provision of health care on signing this authorization, except if the sole purpose of the provision of health care is to create protected health information for disclosure to a third party.

5. I acknowledge that protected health information used and disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal and/or state law.

6. I acknowledge that I have the right to revoke this authorization at any time, except to the extent that protected health information has already been used and disclosed by Provider in reliance on this authorization. I understand that I must revoke this authorization in writing by sending a dated and signed letter stating that I revoke this authorization to the Privacy Officer at the following address: Professional Occupational and Physical Therapy, PLLC, 576 Broadhollow Road, Melville, New York 11747. I acknowledge that the revocation of the authorization will be effective upon receipt of the revocation letter by the Privacy Officer.

By my signature below, I hereby acknowledge that I have read and understand the terms of this authorization, and voluntarily authorize Provider to use and disclose my protected health information set forth above in accordance with this authorization.

Print Name:*

Signature:*

If the signatory is the patient’s personal representative, specify in detail the authority to act on behalf of the patient.

Medical Records Request Fee

Price:

Credit Card*

Cardholder Name

Card Details

Please note: All direct patient requests will be charged a flat fee of $6.50. If a medical records request is for an attorney purposes, cost will be calculated according to the state fees. There is no charge if the records are going directly to a doctor’s office for continuation of treatment purposes.

Medical Records Request

medical records request.

Professional Physical Therapy patients request your medical records here

STEPS:

1. Fill out the form

2. Pay a flat fee of $6.50 to process and release records

3. Your records are delivered via email.

Patients - Request Medical Records

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Data Privacy and Collection Acknowledgement