Medical Record Request

I understand that my pet's records are confidential and cannot be disclosed without my written authorization. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected. 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 the authorization. The authorization will expire six (6) months from the date of my submission, unless I revoke the authorization prior to that time.

A signed copy of this contract and any ancillary or supplement contract or document transmitted by facsimile, email, or other means of electronic transmission and any electronically signed version and delivered version of the contract, and any ancillary or supplement contract or document, shall be deemed to have the same legal effect as delivery of an original executed contract or document for all purposes.

Please be aware that in order for us to release a patient's medical record, we must receive written consent from the mutual client before we can send it over to your facility. They can fill out this form on their end or send us an email (manager@nahah.net). Thank you for your understanding and cooporation.