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The form supports choosing either an abstract of a specific visit date or an entire visit date with complete documentation, including date of service. It also allows selecting specific services or report types by date range, covering diagnostic tests, consultations, radiology, labs, rehabilitation therapies, and other notes. It further includes protected-content consent checkboxes under state or federal law, plus pick-up, mail, email, patient portal, verbal, and fax delivery options.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ns-him-00001-release-of-health-records-form-complete-information/195373/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ns-him-00001-release-of-health-records-form-complete-information/195373.png","ImageObject",442,249,{"name":88,"@type":89},"Himbo","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"What should be selected for Individual Visit(s): Abstract or Entire Visit Date?","Question",{"text":109,"@type":110},"Select Abstract of Visit Date to receive the key commonly requested elements for a specific visit date(s), or select Entire Visit Date to receive any and all documentation related to that visit date(s), including the date of service.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How can I request only certain types of services or reports?",{"text":114,"@type":110},"Check only the report type(s) requested under Specific Services and provide the date or date range for when the services occurred.",{"name":116,"@type":107,"acceptedAnswer":117},"What protected health information requires consent before release?",{"text":118,"@type":110},"Protected content such as abortion-related records, genetic screening results, sexual assault counseling, domestic violence counseling, HIV/AIDS test results, sexually transmitted diseases, and detailed mental health or alcohol/substance use disorder information must be checked; otherwise the information will not be released.",{"name":120,"@type":107,"acceptedAnswer":121},"What delivery methods are available for paper copies and electronic delivery?",{"text":122,"@type":110},"Options include pick-up, mail, email, patient portal (when available and only if the patient has activated an account), verbal, and fax.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},195373,1788447958,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":130,"read_time":9},687197100911,"https://ap-avatar.wpscdn.com/avatar/a000239b6f1da00475?x-image-process=image/resize,m_fixed,w_180,h_180&k=1785132997149421697","| PLEASE COMPLETE THE INFORMATION BELOW: |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Individual Visit(s) . Please check either Abstract or Entire Visit Date box. Your release will include an:\u003Cbr> Abstract of Visit Date. Includes key elements of a specific visit date(s) including: reports, diagnostic testing (labs, x-rays, EKGs, PFTs, medication reconciliation list, allergies and provider’s transcribed reports) . An abstract contains the most commonly requested information and is less expensive.\u003Cbr> Entire Visit Date. Includes any and all documentation related to a specific visit date(s) . Please include the date of service.\u003Cbr>Date(s) From:   Through:   |  |  |  |  |  |  |  |  |  |\n| Specific Services. If you wish to receive ONLY copies of specific service(s), please check ONLY the report type(s) that you are requesting and provide the date/range (when the services occured) on the line below.\u003Cbr>Date(s) From:   Through:   Cardiac Studies-Heart Operative/Procedure Report(s) Consultations Pathology Report(s) Discharge Summaries Patient Discharge Care Form(s) Neurological tests: EEG, EMG, Sleep Study Pulmonary Studies: (Lung) Pulmonary Function Tests Emergency Service Records Radiology Reports Immunization Records Rehabilitation: Physical Therapy, Occupational Therapy, Speech Therapy Laboratory Reports (blood tests) Other (specify): Office/Clinic Notes for Dr   Other (specify): |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |\n| PROTECTED UNDER STATE OR FEDERAL LAW\u003Cbr>I understand that my health record may include information related to my mental health, alcohol/substance use disorder, sexual assault, sexually transmitted diseases, abortion, genetic testing, HIV/AIDS, domestic violence, or other information I may consider sensitive. You must check the box next to the types of content below or that information will NOT be released.\u003Cbr> Abortion-Consent Forms or Court Orders  Genetic Screening Test Results  Sexual Assault Counseling\u003Cbr> Domestic Violence Counseling  HIV/AIDS Test Results  Sexually Transmitted Diseases\u003Cbr> Details of Mental Health Diagnosis and/or Treatment Provided by a Psychologist, Psychiatrist, Mental Health Clinical Nurse Practioner, Licensed Mental Health Couselor, and Licensed Social Worker\u003Cbr> Alcohol/Substance Use Disorder; must specify exact nature of information needed:  \u003Cbr>__________________________________________________________________________________________________________________________________________\u003Cbr>__________________________________________________________________________________________________________________________________________\u003Cbr> OTHER (specify):  \u003Cbr>__________________________________________________________________________________________________________________________________________\u003Cbr>__________________________________________________________________________________________________________________________________________ |  |  |  |  |  |  |  |  |  |\n\n| PICK-UP\u003Cbr> Paper Copies Location:  \u003Cbr>__________________________ | MAIL\u003Cbr> Paper Copies  Email | | PATIENT PORTAL*\u003Cbr>*When available and only if patient has activated his/her account | VERBAL\u003Cbr>| FAX\u003Cbr>\u003Cbr>Fax:   |\n| --- | --- | --- | --- | --- | --- |","cbCaigL8apKqgchA","https://ap.wps.com/l/cbCaigL8apKqgchA","pdf",48602,"English","# Individual Visit(s)\n## Specific Services\n## Protected Information Consent\n# Pick-up and Delivery Options","[{\"question\":\"What should be selected for Individual Visit(s): Abstract or Entire Visit Date?\",\"answer\":\"Select Abstract of Visit Date to receive the key commonly requested elements for a specific visit date(s), or select Entire Visit Date to receive any and all documentation related to that visit date(s), including the date of service.\"},{\"question\":\"How can I request only certain types of services or reports?\",\"answer\":\"Check only the report type(s) requested under Specific Services and provide the date or date range for when the services occurred.\"},{\"question\":\"What protected health information requires consent before release?\",\"answer\":\"Protected content such as abortion-related records, genetic screening results, sexual assault counseling, domestic violence counseling, HIV/AIDS test results, sexually transmitted diseases, and detailed mental health or alcohol/substance use disorder information must be checked; otherwise the information will not be released.\"},{\"question\":\"What delivery methods are available for paper copies and electronic delivery?\",\"answer\":\"Options include pick-up, mail, email, patient portal (when available and only if the patient has activated an account), verbal, and fax.\"}]","NS% HIM 00001 - Release of Health Records Form - Complete Information | PDF"]