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Hippa-Release

Indiana Clinical Research-HIPAA Release Medical Record Request

HIPAA Release Medical Record Request

INFORMATION TO BE RELEASED FROM

PRIMARY CARE PHYSICIAN RELEASE

Primary Care Physician
It may be important for your physician to receive records from Indiana Clinical Research (IMRI). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from SCT, a signed authorization form must be received. Without your authorization, IMRI will not release any information.

MUST SELECT AT LEAST ONE OPTION

I DO authorize PCT to release all study related records to the physician above.

I DO NOT authorize MCR to release any study related records to the physician above.

Indiana Clinical Research RELEASE

Indiana Clinical Research
It may be important for IMRI to contact your physician and/or receive medical records from your physician in order for us to determine your eligibility for the study. In order for SCT to contact or receive medical records from your physician, a sign authorization form must be completed. Without your authorization, we will not contact or request medical records from your physician.

MUST SELECT AT LEAST ONE OPTION

MCR Release

I DO authorize my personal physician to provide my medical records to PCT.

I DO NOT authorize my personal physician to provide my medical records to PCT.

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