* REQUEST FOR MEDICAL RECORDS - Office of Dr. Byron J. Van Dyke, M.D. (Dermatology) *
Your most recent clinic note should contain a summary of all previous skin cancer surgeries, so please keep this in mind when deciding which records to request.
Byron J. Van Dyke, M.D., Dermatology
www.DrVanDyke.com
Tel (530) 247-7546 * Fax (530) 247-7228
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The undersigned PATIENT or patient's legal REPRESENTATIVE hereby requests access to the Medical Records of:
PATIENT INFORMATION
First name, middle initial, and last name.
Number and Street name
We will copy this EXACTLY as you write it (upper-case and lower-case, symbols, etc). We will email records to this address if you choose this option.
ONLY list if you want us to fax these records.
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NO CHARGE to send most recent note to your doctor
We do not charge to send a copy of the most recent clinic note to your other doctors.
Leave blank of not sending to other practitioners.
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CHARGE for Additional Records ($10 paid at time of request)
There is a charge of $10 for the first 30 pages of each record sent out (if you need more than the most recent note sent to your doctor). Each additional page is 25 cents.
If you are requesting more than just the most recent clinical note sent to your other doctors, please pay $10 for EACH party receiving records.. We will ask for the remainder if there are more than 30 pages. You can pay via PayPal/credit card using the link on our web page OR send a check to: Byron J. Van Dyke, M.D, PO Box 994505, Redding, CA 96099-4505
Please use a "temporary" password (in particular, one different from that used for your Email). You will receive a link in your Email inbox to download the records. These will arrive as a PDF file. After you download the records you can open the document using the password you provided (and you can save again without a password if you wish).
Leave blank if NOT mailing records.
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Limitations
1. I understand that IF I AM A PARENT making a request regarding records of a minor, I will not be shown entries for health care to which, by law, the minor may consent without parental involvement. I understand that IF I AM A MINOR, I will be given access only to those portions of my record describing health care for which I may consent, under applicable law.
2. I understand that records of mental health care or alcohol or drug abuse treatment may not be disclosed to me directly if the health care provider determines that to do so would present a risk of significant adverse or detrimental consequences. I understand that the provider may provide me with a summary of the requested records instead of copying or providing the oricinal records for examination. I understand I then may designate a physician, licensed psychologist, or clinical social worker to review the record on my behalf.
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I have reviewed and fully completed these forms to the best of my ability. I understand this information will become part of my permanent medical record.
Please print your first and last name. This constitutes your electronic signature for this entire document.
Just press the "Return" key to choose today's date.
Once finished, click the "SUBMIT: button. You should see 'Form..." successfully submitted. If NOT, then check the top of this page for any missing fields to correct, and try submitting again.
