Request for PHI

Requestfor PHI (Personal Health Information)

OUR PHI DATA RETENTION POLICY

It is the policy of BoxedRX to maintain files for patients who receive services from BoxedRX. This policy includes active patients who regularly receive company services, and those who purchase services through third-party payer sources. This policy does not apply to simple cash sales transactions for one-time sales of medical products. Documentation in the patient record should occur within 24 hours of any service, care or treatment provided. The patient record must be complete and audited for completion before it can be billed and filed.

For a complete set of policies and discolsures regarding your medical record and your rights to access, restrict, modify and remove this information, please read our Patient Handbook.

Medical Records Request

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Address *

Records From Date *

Records To Date *

Delivery Method *

Email

Mail

Type of Records Requested *

I authorize the release of my medical records as specified in this request. I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice.

I consent to the release of my medical records as specified above *

We respect your right to privacy. Any personal information you provide, including your contact details, will be kept strictly confidential. We will never sell, trade, or share your information with third parties for marketing purposes. Your trust is important to us, and we are committed to protecting your privacy. Please be sure to read the BoxedRX Privacy Policy.

This web form is protected by hCaptcha and their Privacy Policy and Terms of Service apply.

Medical Records Request

Policies

Patients