HIPAA Form


Please Fill In The Following Text Boxes:
Patient's Name (required)
Date of Birth (required) DD-MM-YYYY
Address (required)
City (required)
State (required)
Zip (required)
Phone (required)
Email
Social Security Number (last 4 digits required)
I hereby authorize:
Aspen Health & Wellness (a subsidiary of Aspen Clinical Research, LLC)

1215 South 1680 West, Orem UT 84058

Phone: 801-356-5555

To receive the patient's medical record from:
Name of Provider (Physician)
Name of Clinic/Hospital
Address
City
State
Zip
Provider Phone
Fax

My health information may be disclosed, stored and reviewed by my attending physician, office staff, and other related parties in review of quality of care, risk management, and clinical research studies.

I agree that the following information may be reviewed and released: (Identifying information will not be shared).

  • Demographics (Name, Address, Age, Sex and Race)
  • Behavioral health services/psychiatric care.
  • Diagnostic/Medical/Surgical History
  • Infectious Diseases and Treatment History
  • Treatment for alcohol and/or drug abuse
  • Past and Current Medication Therapies

This information may be used for one or more of the following purposes:

  • Medical Treatment and/or Review
  • Clinical Research Review and study
  • Release of Information to organizations including government agencies and for clinical research reporting.

I understand that my health information will be saved at the above referenced address in a confidential database. I understand that the physician and other authorized staff agrees not to share my confidential information, except as authorized by law.

Affirmation of Release

I authorize the above named agency and give permission to release the information indicated on this form to the individual(s) or agency(s) I have named and only for the purposes written. I understand that this release is valid for up to 15 years from the date I sign it and I may refuse to sign this authorization or revoke it at any time. Any revocation or refusal to sign this authorization will not affect my ability to obtain treatment or payment or my eligibility for benefits. The revocation will take effect when it is received in writing. As a patient I have the right to access my treatment records during ongoing treatment records during ongoing treatment and after discharge. Copies of the records may be obtained with reasonable notice and payment of copying costs.

Electronic Signature

First Name (required):
Middle Initial (required):
Last Name (required):
captcha
Enter the letters below: