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Hippa Release Form

Scottsdale Clinical Trials-HIPAA Release Medical Record Request

INFORMATION TO BE RELEASED FROM

PRIMARY CARE PHYSICIAN RELEASE Primary Care Physician It may be important for your physician to receive records from Scottsdale Clinical Trials (SCT). In order for your physician to receive medical information, (i.e. lab reports, EKG, etc.) from SCT, a signed authorization form must be received. Without your authorization, SCT will not release any information. MUST SELECT AT LEAST ONE OPTION

I DO authorize PCT to release all study related records to the physician above.

I DO NOT authorize MCR to release any study related records to the physician above.

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May 22, 2025 11:17 pm MST

Hippa Release Form Uploaded by Hector Calderon - [email protected] IP 24.11.149.164