Patient's Medical History Check all that apply for your child. Enter the date diagnosed in the small date box.
Musculoskeletal / Rheumatology Gastrointestinal / Nephrology / Endocrinology Lifestyle / Recreational Abuse History Surgical History Add surgery Other Healthcare Providers Add provider Continue
Authorization for Medical Records Request Reason: Continuity of Care
Release to:
Information contained in the medical record of:
Patient Name* Date of Birth*
Last 4 of SSN* Patient name and date of birth are filled from the first page.
Information requested:
Admission/Discharge Summaries Contact / Nursing Notes Diagnostic and Surgical Consults/Reports and related Media Medication Administration Record (MAR) The above entity is authorized to receive this information even though the confidentiality of the information may be protected by federal or state law regulations. CRP is hereby released and discharged from any liability and the undersigned will hold CRP harmless for complying with this authorization to release medical information. I am authorizing release of my medical records and other information regarding my treatment, including psychological or psychiatric impairments, drug abuse, alcoholism, sickle-cell anemia, acquired immunodeficiency syndrome (AIDS), or test for infection with human immunodeficiency virus (HIV).
This authorization does not expire. You may revoke this authorization with a written request submitted to the address noted above. A copy of this form with my signature will constitute as an original signature.
Date* Patient Signature*
Clear signature
If the patient is under 18 or has a legally appointed guardian, a parent or guardian must also sign. Staff complete that section. v. 23 FEB 2021
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Notice of Deemed Consent for HIV, Hepatitis B or C Testing Clinical Research Partners, LLC. is required by section 32.1-45.1 of the Code of Virginia (1950), as amended, to give you the following notice:
1. If any Clinical Research Partners, LLC health care professional, worker or employee should be directly exposed to your blood or body fluids in a way that may transmit disease, your blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health care provider will tell you the result of the test. Under Va. Code section 32.1-45.1(A), you are deemed to have consented to the release of the test results to the person exposed.
2. If you should be directly exposed to blood or body fluids of a Clinical Research Partners, LLC health care professional, worker or employee in a way that may transmit disease, that person's blood will be tested for infection with human immunodeficiency virus (HIV), as well as for Hepatitis B and C. A physician or other health care provider will tell you and that person the result of the test.
Deemed Consent: I understand that under Virginia law if, while examining or treating me, any person employed by or under the direction and control of Clinical Research Partners, LLC., or any other healthcare provider is directly exposed to my body fluids in a manner which may transmit HIV, Hepatitis B or Hepatitis C, I will be deemed to have consented to testing for HIV, Hepatitis B or Hepatitis C infection and to the release of the test results to the exposed person.
Print Name* Date of Birth*
Print name and date of birth are filled from the first page. Staff complete the witness signature.
Date* Signature Date* Signature*
Clear signature
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