Baycare Patient Record Requests

Disclose To / Send Records To Patient
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Disclose From / Obtain Records From
Obtain Records from this Healthcare Provider
Hospital or Facility Name*
Physician Name(s)
Phone Number*
Location*
City State
Patient Information
Same as Above*
- Yes
- No
Patient Name*
Date of Birth*
Patient's Phone
Patient's Email
Requested Information
Dates of Treatment
Please provide a copy of patient's medical records for the following date range:
Beginning Date of Treatment*
MM slash DD slash YYYY
Ending Date of Treatment*
MM slash DD slash YYYY
Records to Release*
- COVID-19 Test Results
- Physician Documents (Pertinent Reports and Test Results for Doctors)
- Patient Personal Documents (All Provider and Test Results – no nurses’ notes, phone calls, etc.)
- Emergency Room
- Doctor's Notes
- Discharge Summary
- Nurse's Notes
- EKG
- Labs
- Immunizations
- Admission Sheet
- Physician's Orders
- Pathology Reports
- History/Physical
- Office Notes
- Progress Notes
- Operative Reports
- Consultation
- Radiology
- Radiology Films / Imaging
- Entire Chart – please be aware this will include the designated record set and may go into thousands of pages
- Itemized Medical Billing
Disclosure Purpose*
Please indicate your acceptance by checking the following boxes:*
- I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon this authorization (45 CFR 164.508(c)(2)(i)).
- I understand that treatment or payment cannot be conditioned on my signing this authorization, except in certain circumstances such as for participation in research programs, or authorization of the release of testing results for pre-employment purposes (45 CFR 164.508(c)(2)(i)).
- I understand that my records are confidential and cannot be disclosed without my written authorization except when otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected.
- I understand that the specified information to be released may include, but is not limited to: history, diagnosis, and/or treatment of drug or alcohol abuse, mental illness, communicable disease, including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) (45 CFR 164.508(c)(2)(i)).
- I understand my request will not be processed until the patient's identity has been confirmed by telephone
Delivery Format
Deliver Records By*
- Electronic Delivery (Secure Email)
- Mail Delivery – CD
- Pushed to Patient Portal (where available)
- Mail Delivery – Paper
Set Password for Secure Electronic Delivery*

Be sure to record this password in order to later access your electronically delivered medical records once they've been delivered to your specified email address.
Set Password for Secure Electronic Delivery (Optional)

Be sure to record this password in order to later access your electronically delivered medical records once they've been delivered to your specified email address.
Authorization
Name*
First Last
Relationship to Patient*
Patient authorization shall remain valid for:*
- 30 Days
- 60 Days
- 90 Days
- 180 Days
- 365 Days
This authorization will expire after the selected validity period (above) as authorized by my signature unless I revoke the authorization prior to that time.*

Patient or Legally Authorized Representative
Signature*
Confirm Acknowledgement of Disclosure*
- I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to disclosure of medical records.
Additional Comments (optional)
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Request Medical Records from BayCare

BayCare processes medical record requests through ScanSTAT Technologies. Questions regarding your request can be submitted to information@ScanSTAT.com.

Disclose To / Send Records To Patient

Disclose From / Obtain Records From

Patient Information

Requested Information

Delivery Format

Authorization