Medical Authorization Online Medical Consent Form Submission ID Site ID Patient Information Name* First NameLast Name Date of Birth* -Month -DayYear Sex at Birth* Please Select Male Female Email Phone Number* Address* Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Authorization for Use/Disclosure of Health Information: I hereby authorize health information which includes the patient's entire medical record, including Protected Health Information, Sensitive Health Information and diagnosis formation relating to any medical history, mental or physical condition, and any treatment received by the patient, to be released by all medical providers including the provider below: Provide Physician Information Below: Physician Name * First NameLast Name Physician Number Please enter a valid phone number. Fax Number Please enter a valid phone number. Physician Address Street Address Street Address Line 2 City Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code To The Following Individual: Clincloud Research Purpose: I authorize the release of the written health information and exchange of oral communication patient health information for the purpose of continuity of care or record review for research study participation. Information to be Disclosed and Exchanged: I authorize the release of all of the patient health information that any provider has in his or her possession, including information relating to any medical history, mental or physical condition, and any treatment received by me. This includes but is not limited to office visit notes, progress notes, and laboratory results. Expiration of Authorization: Unless otherwise revoked, this authorization does not expire except in states where unlimited authorization is not permitted, in which case it expires 50 years from the date of signature. Notice: Clincloud Research and many other organizations and individuals, such as physicians, hospitals, and health plans, are required by law to keep your health information confidential. However, information disclosed under this authorization might be redisclosed by the recipient, and the redisclosure may no longer be protected by federal or state law. Refusal to sign/Right to Revoke: I understand that this authorization to release health information is voluntary. I can revoke this authorization by providing a written notice of revocation to the address listed below. Revocation will be effective upon Clincloud Research’s receipt and will not have any effect on any action taken in reliance of this Authorization before written notice of revocation was received. I need not sign this form to ensure healthcare treatment from a healthcare or medical facility or provider. I understand that I have a right to receive a copy of this form and that it is made accessible to me. Questions: I understand that I may contact ClinCloud Research for answers to the patient questions about this form at 1551 Sandspur Road, Maitland, FL 32751 or by telephone at (407) 801-4438. Acknowledgment, Authorization and Waiver * I have read and understand the information in this authorization to release the patient health information. Patient/Parent/Guardian Signature* Date Signed* -Month -DayYear SubmitSubmit Should be Empty:
