Patient Medical Record Release/Access Form

Patient Medical Record Release Request

Health Information Management Department
The following form is to request any patient medical records from Doctors Hospital (Bahamas) Limited. Please read through the form carefully before submitting.

ALL CORRESPONDENCE REGARDING MEDICAL RECORD RELEASE REQUEST WILL BE VIA EMAIL.

A VALID EMAIL ADDRESS IS REQUIRED IN ORDER TO SUBMIT THIS REQUEST.

DOCTORS HOSPITAL

HEALTH INFORMATION DEPARTMENT

EMAIL: him@doctorshosp.com

Terms and Conditions

Please read the following terms carefully.

Patient Details
Is the patient or another individual requesting medical records on behalf of the patient?:*

PatientAnother Individual
Name of Individual:*

First NameLast Name
Relationship to Patient:*
Patient's Name:*

First NameLast Name
Patient's Date of Birth:*

DayMonthYear
Date
Email Address (All correspondence regarding the Medical Record Request will be sent to this email address):*

Confirmation EmailPlease ensure the email address listed here is regularly accessed as confirmation emails and other notifications will be sent to this email.
Telephone Contact: *
Please enter a valid phone number.Format: (000) 000-0000.
Patient Address: *

Street Address

Street Address Line 2

City/SettlementState / Province/Island

P.O. Box / Zip CodeCountry
Information Required & Date of Service (please enter the information that you require and state the respective date of service): *
Signature of Individual Completing Form (Patient or Other Individual):*

Clear
Government Issued Photo ID Upload

Please note that requests will be denied unless Government Issued Photo IDs are uploaded correctly for the patient and/or the requester.
Patient Government Issued Photo ID: *

Accepted Formants: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Individual [submitting request on behalf of patient] Government Issued Photo ID:*

Accepted Formants: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Delivery of Records
Purpose of Medical Records Request:*
Method of Delivery:*
Format of Records (Hard Copy, CD):*
Medical Records are being delivered to:*
Please provide some clarity/explanation as to where the medical records are going: *
Recipient of Patient Medical Records other than the Patient:*
Please enter the name of the Medical Institution or the Clinical Practitioner
Address of Recipient (Medical Institution or Clinical Practitioner):*

Street Address

Street Address Line 2

City/SettlementState/Province/Island

P.O. Box/Zip CodeCountry
Should be Empty:

Patient Medical Record Release Request

Terms and Conditions

Patient Details

Government Issued Photo ID Upload

Delivery of Records