REQUEST FOR MEDICAL RECORDS                      

 

DATE OF REQUEST: _________________________

 

PATIENT INFORMATION

Patient Name (Print):

 

Date of Birth:

 

 

Name and address of Doctor that records are being authorized to be released from:

Name:

 

Address:

 

Phone #:

 

 

SEND THE FOLLOWING RECORDS/REPORTS/FILMS:

  • Medical/Chiropractic Records (Recent records only). Do not include billing records.
  • Medical/Chiropractic Records (All past records.) Do not include billing records.
  • Imaging report and films _____________________________________________
  • Lab reports

 

SEND MEDICAL/CHIROPRACTIC RECORDS TO:

The following Doctor/Facility has authorization from this patient to request release of medical records to:

Doctor’s Name:

Christine Teaño Lipat, DC, Niu Health Chiropractic

License #:

1182

Address:

1110 University Ave, Ste 304, Honolulu, HI 96826

Phone #:

(808) 783-1046

Z-sentry secure e-mail:

niupatients@gmail.com

I, (Patient, print name) _______________________________, hereby request and authorize the above records to be released and mailed to the doctor/facility indicated in this form.  It is understood that any X-ray original films will be returned to the originating facility within 30 days after receiving them.

Signature of Patient:_____________________________________________________  Date: ______________