Well Timed Healthcare LLC
Acknowledgment of Receipt of Notice of Privacy Practices
PLEASE COMPLETE ALL SECTIONS OF THIS FORM FOR THE RELEASE OF YOUR MEDICAL RECORDS. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 301 401 7999.
PATIENT’S NAME: _____________________________________ DATE OF BIRTH: ____________
ADDRESS: ______________________________________________________________________
CITY, STATE, ZIP: __________________________________________________________________
YOUR PHONE NUMBER: ______________________________
By signing this form, I verify that I am the patient, or the parent, /legal guardian of the child or children, that is name above, with the authority to request medical records, and I authorize WELL TIMED HEALTHCARE, LLC to To Obtain medical records from To Release copies of my medical records to
Name of the Clinic or /Provider/Physician: ______________________________________________
Complete Address: __________________________________________________________
Phone Number: ________________________ Fax Number: _________________________________________
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Reason for the Disclosure: ☐ Moving ☐ Change of Insurance ☐ Specialist ☐ Other (specify)________________________________________________________________________________________
Information to be Disclosed: ☐ Complete Medical Record ☐ Full Medical Record with the following exclusions: __________________________________________ _________________________________________________________________________________________ ☐ Basic Medical Record (Medication List, Immunizations, Vitals, Last Well Visit Note) ☐ Other: __________________________________________________________________________________
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This authorization will expire 1 year from the date I have signed this form. I understand that I may revoke this authorization at any time by notifying Well Timed Healthcare in writing and it will be effective on the date notified, except to the extent action has already been taken in reliance upon it. By my signature on this form, I also agree to pay any requested fees as established by my state law. By Signing Below, I Am Agreeing That I Have Read, Understood and Agree to The Items Contained in this Document On This Date. Please enter your full legal name as your electronic signature.
Print Your Full Legal Name _______________________________________________________
To be signed by patient’s parent or legal guardian if patient is a minor or otherwise not competent
Name and Relationship of Person Signing, if not Patient:
Your full legal name as your electronic signature. ____________________________