Electronic Health Information Request Form

In compliance with the CURES Act, the form provided below is for entities or agents representing an entity to submit a request for Electronic Health Information (EHI) . Upon submission, responses to requests will be provided within ten (10) business days.

Note: If you are a patient looking for medical records for yourself or you are a proxy for a patient, please visit our medical records page. If you are a physician needing access to a patient鈥檚 record, please contact HIMS.

Please do not include PHI in your form submission.

Information About You

* All fields are required

(Please write 鈥淣one鈥� if not applicable.)
Do you want the information sent from 天博体育?

 

Information About the Represented Company

(Please write 鈥淪ame鈥� if same as company you鈥檙e with.)

(Please write 鈥淣one鈥� if not applicable.)

(Please write 鈥淣one鈥� if not applicable.)
 

Information About Your Request

 

Allergies and Intolerances - Drug Class

Allergies and Intolerances - Medication

Allergies and Intolerances - Reaction

Assessment and Plan of Treatment

Care Team Member(s)

Clinical Notes - Consultation Note

Clinical Notes - Discharge Summary Note

Clinical Notes - History & Physical

Clinical Notes - Imaging Narrative

Clinical Notes - Laboratory Report Narrative

Clinical Notes - Pathology Report Narrative

Clinical Notes - Procedure Note

Clinical Notes - Progress Note

Patients Goals

Health Concerns

Immunizations

Laboratory - Tests

Laboratory - Values/Results

Medications

Patient Demographics - First Name

Patient Demographics - Last Name

Patient Demographics - Previous Name

Patient Demographics -

Patient Demographics - Middle Name

Patient Demographics - Suffix

Patient Demographics - Birth Sex

Patient Demographics - Date of Birth

Patient Demographics - Race

Patient Demographics - Ethnicity

Patient Demographics - Preferred Language

Patient Demographics - Current Address

Patient Demographics - Previous Address

Patient Demographics - Phone Number

Patient Demographics - Phone Number Type

Patient Demographics - Email Address

Problems

Procedures

Provenance - Author Time Stamp

Provenance - Author Organization

Smoking Status

Unique Device Identifier(s) for patient

Vital Signs - Diastolic blood pressure

Vital Signs - Systolic blood pressure

Vital Signs - Body height

Vital Signs - Body weight

Vital Signs - Respiratory rate

Vital Signs - Body temperature

Vital Signs - Pulse oximetry

Vital Signs - Inhaled oxygen concentration

Vital Signs - BMI Percentile (2 - 20 years)

Vital Signs - Weight-for-length Percentile

Vital Signs - Head Occipital-frontal

Vital Signs - Circumference(Birth-36 Months)

None of the Above

 

Information About Your Legal Authority

Do you have patient authorization or a patient consent form?
Does your organization have a SOC II report or similar third party audit report on Security Controls (e.g., HITRUST Certification)?
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