Marvel Clinical Research. Clinical Research Trials in Orange County, California.

Marvel - HIPAA Release Medical Record Request


HIPAA Release Medical Record Request

 

 

INFORMATION TO BE RELEASED FROM

Phone: 

PRIMARY CARE PHYSICIAN RELEASE

Primary Care Physician
It may be important for your physician to receive records from Marvel Clinical Research (MCR). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from MCR, a signed authorization form must be received. Without your authorization, MCR will not release any information.

MUST SELECT AT LEAST ONE OPTION

  Release

 

MARVEL CLINICAL RESEARCH RELEASE

Marvel Clinical Research
It may be important for MCR to contact your physician and/or receive medical records from your physician in order for us to determine your eligibility for the study. In order for MCR to contact or receive medical records from your physician, a sign authorization form must be completed. Without your authorization, we will not contact or request medical records from your physician.

MUST SELECT AT LEAST ONE OPTION

MCR Release

Proprietary and Confidential | Version 1.0 (1AUG2016)

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Marvel Clinical Research. Clinical Research Trials in Orange County, California. https://marvelclinical.com
Signature Certificate
Document name: Marvel - HIPAA Release Medical Record Request
Unique Document ID: 9689ec8a0b90e9d6c44b24dd7797b9b9a408fc0f
Timestamp Audit
June 8, 2016 3:22 pm PSTMarvel - HIPAA Release Medical Record Request Uploaded by Marvel Clinical Research - info@marvelclinical.com IP 104.182.58.26