Questionnaire - FASTER DRAFT

Who is Sender?

A person who sends and signs this form is:
- Patient
- Patient's representative (e.g., attorney or guardian)
Indicate the patient's full name:
Indicate the patient's full residential address:
Indicate the patient's contact email address and phone number:
Indicate the patient's date of birth:
Indicate the full name of the patient's representative:

!
A patient’s representative could be their immediate family member acting as a legal guardian, court-appointed guardian or an attorney.
Indicate the full residential address of the patient's representative:
Indicate contact email address of the representative:

Who is Recipient?

A person to whom this form is being sent is:
- Doctor or medical practitioner
- Hospital or medical institution
Indicate the name of a doctor/medical practitioner to whom this form is addressed:
Provide the doctor’s complete business address:
Indicate the full name of a hospital or medical institution:
Indicate address of the hospital or medical institution:

About the Request

Select the date on which the sender signs this form:
State the reason or reasons for requesting access to the medical records:
The sender requests access to:
- all available medical records
- specific records
List the types of medical records to which the access should be given:
Indicate the preferred format for receiving the requested information:
The release given under this form shall remain valid for the period of:

!
The maximum duration of the authorization cannot exceed twelve months.

Miscellaneous

The patient is:
- former patient
- current patient
Provide the full names of individuals and/or organizations authorized to access the patient’s medical records:
Does the patient consent to the release of information regarding their drug or alcohol use?
- No
- Yes
Does the patient consent to the release of information regarding their mental health?
- No
- Yes
Does the patient consent to the release of information regarding their HIV status?
- No
- Yes
Indicate the exact types of the patient's medical information to which access cannot be given at all:

Do you want to add a signature?
- Yes
- No
Add signature:

Select a template's format:

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Skipped answers will appear as blank part in the text of the final document. You can fill them in at later stage.

Who is Sender?

A person who sends and signs this form is:

Indicate the patient's full name:

Indicate the patient's full residential address:

Indicate the patient's contact email address and phone number:

Indicate the patient's date of birth:

Indicate the full name of the patient's representative:

Indicate the full residential address of the patient's representative:

Indicate contact email address of the representative:

Who is Recipient?

A person to whom this form is being sent is:

Indicate the name of a doctor/medical practitioner to whom this form is addressed:

Provide the doctor’s complete business address:

Indicate the full name of a hospital or medical institution:

Indicate address of the hospital or medical institution:

About the Request

Select the date on which the sender signs this form:

State the reason or reasons for requesting access to the medical records:

The sender requests access to:

List the types of medical records to which the access should be given:

Indicate the preferred format for receiving the requested information:

The release given under this form shall remain valid for the period of:

Miscellaneous

The patient is:

Provide the full names of individuals and/or organizations authorized to access the patient’s medical records:

Does the patient consent to the release of information regarding their drug or alcohol use?

Does the patient consent to the release of information regarding their mental health?

Does the patient consent to the release of information regarding their HIV status?

Indicate the exact types of the patient's medical information to which access cannot be given at all:

Do you want to add a signature?

Add signature:

Select a template's format: