Free Medical Record Access Template
Medical Record Access
A. Patient Information:
|
Field |
Details |
|---|---|
|
Patient Name |
Golda Larson |
|
Date of Birth |
July 15, 2050 |
|
Gender |
Female |
|
Patient ID |
JD2090-001 |
|
Primary Contact Number |
222 555 7777 |
|
Address |
Modesto, CA 95350 |
|
Emergency Contact Name |
Kevin Larson |
|
Emergency Contact Number |
222 555 7777 |
B. Medical History:
|
Condition |
Details |
|---|---|
|
Past Medical History |
Hypertension, Asthma |
|
Allergies |
Penicillin |
|
Medications |
Lisinopril, Albuterol Inhaler |
|
Surgeries |
Appendectomy (2065) |
|
Family Medical History |
Father: Heart Disease; Mother: Diabetes |
C. Physician Information:
|
Field |
Details |
|---|---|
|
Primary Care Physician |
Dr. Sarah Montgomery |
|
Specialist Name (if any) |
Dr. Emily Williams (Pulmonologist) |
|
Hospital/Clinic Name |
[YOUR COMPANY NAME] |
|
Address |
Modesto, CA 95350 |
|
Contact Information |
[YOUR COMPANY EMAIL] |
D. Access Permissions:
|
Access Granted To |
Details |
|---|---|
|
Authorized Person/Entity |
JanusCo |
|
Reason for Access |
Insurance Claim Processing |
|
Date of Access Request |
March 10, 2090 |
|
Date of Access Granted |
March 12, 2090 |
E. Medical Record Release:
I, Golda Larson, hereby authorize the release of my medical records to JanusCo for the purpose of insurance claim processing. I understand that this release does not extend beyond the specific purpose described above and is granted in compliance with privacy and confidentiality laws.
Date: March 12, 2090
F. Confidentiality and Compliance:
All medical records accessed, reviewed, or shared under this document are subject to strict confidentiality rules and regulations, including but not limited to HIPAA (Health Insurance Portability and Accountability Act) compliance. Any unauthorized access, distribution, or use of the records is prohibited and may result in legal consequences.
G. Additional Notes:
-
Patient requires annual asthma check-ups.
-
Allergies to penicillin must be noted before prescribing any medication.
For Office Use Only:
|
Field |
Details |
|---|---|
|
Record Checked By |
Dr. Sarah Montgomery |
|
Date of Verification |
March 12, 2090 |
|
Access Granted By |
[YOUR NAME] (Records Coordinator) |
|
Date Access Revoked (if applicable) |
N/A |
