RECORDS REQUEST

ATTN: Medical Records Coordinator; The Woman's Group, P.A.

Patient Name*

First Last

Patient Home / Mailing Address*

Street Address Address Line 2 City State ZIP Code

Patient Date of Birth (DOB)*

Social Security Number (Last 4 Only)*

Form Filler Relationship to Patient*

Name of Form Filler*

If the person filling out this request is not the patient, please provide the full name of the form filler here. Please note that this person must have legal rights to the patient records being requested.

Where can you be reached during business hours?

If we have questions or need further verification, we will need to reach you by email or phone.

Patient Email On-File with The Woman's Group*

Enter Email Confirm Email

*Please note that we follow all HIPAA guidelines to protect private patient health information. Online submissions for records requests will only be released to the patient of record or to a TWG approved, legally appointed advocate or representative, using the last email we have on file for the patient of record. If any part of the patient information submitted does not match our files, records will not be released. We still invite all patients with outdated information and appointed advocates and representatives who need records to continue filling out this form and add notes below describing the situation. Our Records Request Coordinator will reach out to the email and/or phone provided to work with you regarding the supporting documents which will be required to proceed. We appreciate your understanding as we protect and honor the privacy of each patient.

Best Phone Number*

Alternate Phone Number

Please Choose Type of Record Request*

Authorizing the Request for Records Disclosure
For Obstetrics patients who are transferring their care to The Woman's Group and Gynecology patients who are referred to The Woman's Group for a particular reason, TWG reserves the right to condition treatment or payment of care based on authorizing the release of pertinent medical records.

Reason for Records Request*

Description of Other, Please*

Please Provide the Name, Address, Phone Number and Fax of the Practice or Facility.*

Please choose which type of records are being requested.*

RECORDS WHICH ARE CONFINED TO ADMISSION AND TREATMENT FOR A SPECIFIC MEDICAL CONDITION.
RECORDS WHICH COVER A SPECIFIC PERIOD OF TIME/DATES.
RECORDS WHICH ARE CONFINED TO SPECIFIC INFORMATION PROVIDED HERE.
RECORDS WHICH HAVE NO LIMITATIONS PLACED ON DATES, HISTORY OR ILLNESS, OR DIAGNOSTIC AND THERAPEUTIC INFORMATION, INCLUDING ANY TREATMENT FOR ALCOHOL AND DRUG ABUSE AS PROTECED BY FEDERAL REGULATION 42CFR, Part 2, PSYCHIATRIC/PSYCHOLOGICAL INFORMATION AND AIDS RELATED INFORMATION, INCLUDING TESTING, FS 490.32, AND/OR 90.503, 381.609.

Please describe the specific medical condition this records request covers.*

Please indicate the specific period of time/dates this record request covers.*

Please explain the specific information this record request covers.*

Please Choose*

Regular Request (Estimated between 10 and 14 business days)
Expedited Request (Estimated between 7 and 10 business days)

*If you choose an expedited request, please take the time to explain your circumstance in the optional notes below. We take patient needs seriously. Requests will be handled in the order they are received with priority offered to requests which include an explanation of expedited need. Upon submission of this form, you will receive an email with the phone number and extension of our Records Request Coordinator. If you have an emergency regarding this request, you may call and leave her a message which will be returned at her first opportunity. Please know that all of our patients' needs are important to us and we will always do our best to accommodate. | Respectfully, The Woman's Group Management

Optional: For additional notes, expedited request explanations, comments, or questions.

This field has a 10,000 character max. That's about 1,500 words or roughly 6 paragraphs.

Date The Request Is Submitted*

Expiration of Authorization*

I understand that regardless of my choice at this time, I may elect to revoke this authorization at any time by sending a request in writing to: Records Coordinator; The Woman's Group, 5380 Primrose Lake Circle, Tampa, FL 33647

No Expiration Date
Expires 90 Days from Request
Expires on a Specific Date

Specific Date of Expiration*

Upload ID and Any Other Support Documents Here*

Please upload a clear image of one of the following: State Id Card, Passport, or a Drivers License.

Drop files here or

Accepted file types: pdf, jpg, png, Max. file size: 15 MB, Max. files: 4.

Certification and Acknowledgement of Records Request*

I certify that I am the patient of record and/or I have the right to request access to or request the sharing of this patient's personal health information as recognized by law. I recognize that The Woman's Group will not release information to me unless all requests for verification are met and all information accurately matches our records. Furthermore, I recognize that this submission will be saved and recorded for all legal purposes.

I have read and understand this certification and acknowledge the requirements of this formal records request.

Authorized Digital Signature of Patient and/or Legally Authorized Advocate or Representative of Patient*

I confirm this digital signature/mark is a legally binding signature made by myself, the patient, or myself, the legally authorized advocate or representative form filler on behalf of the patient.

Email

This field is for validation purposes and should be left unchanged.

Records Request

Request your patient records online

Records Request

Where can you be reached during business hours?

PATIENT ACCESS