Your Contact Information

• Name:
• Title:
• Organization:

Provider Identity

• Primary Location Name: *
• Primary Location Address: *

Patient Fees

• Enter processing fee to be charged for patient requests for medical records. Enter "NA" if an item does not apply.
• Written Records:
• Imaging CD:
• Will the patient be given the option to direct their records to another Healthcare Provider?:

  Yes
  No
  
• Will the patient be given the option to direct their records to a non-Provider third party?:

  Yes
  No
  
• Explain any variations in above-stated patient fee below.:

Turnaround Times

• Enter processing turnaround time in hours or days. Do not factor in any non-web delivery timeframes here.
• Written Records:
• Imaging CDs:

Processing Responsibility

• Indicate if "Service Company" or "Provider" will process the PHI for the following categories.
• Written Records:

  Service Company
  Provider
  
• Imaging CDs:

  Service Company
  Provider
  

Patient-Specific Delivery Methods and Mail Timeframes

• Select all patient delivery options offered for specified record type. For pick-up, please specify pick-up location, including facility, city/state, building, floor, or other details to be communicated to patients.
• Written Records (if applicable):

  Online via TRIMSNet
  Pick-up (specify location below)
  Mail
  Fax
  
• Imaging CD (if applicable):

  Mail (specify mail delivery time below)
  Pick-Up (specify location below)
  
• Pick-up Location(s):
• Mail Delivery Time:

Delivery Responsibility to Patients

• Which patient-specific delivery methods will the Provider be solely responsible for?
• Written Records (if applicable):

  Online via TRIMSNet
  Pick-up
  Mail
  Fax
  
• Imaging CD (if applicable):

  Mail
  Pick-up
  

Release Restrictions

• In the Provider’s state, what is the age of majority for patients to request their own medical records?
• Years Old?:
• If Provider has locations in other states, specify those states and ages of majority:
• Specify restrictions regarding who is allowed to order records on a patient’s behalf and what documents must be submitted or on file with Provider to do so.
• Will Physical Therapy records be included in the standard release of records to the patient?:

  Yes
  No
  

Provider Locations Using TRIMSNet

• Which provider location(s) will use TRIMSNet? Attached sheet if needed:

Contact for Provider Medical Records Management

• Enter contact information for provider’s HIM/practice manager.
• Contact Name and Job Title:
• Email Address:
• Phone Number:

Contact for Provider IT

• Enter contact information for person/company responsible for Provider IT.
• Contact Name:
• Email Address:
• Phone Number:

Contact for Provider Website Modification

• Enter contact information for person/company responsible for editing provider’s website, if applicable.
• Contact Name:
• Email Address:
• Phone Number:

Provider’s Contact Information for Referring Requestor Inquiries

• Enter contact information to be given to patients and other Requestors who need to speak directly to provider regarding their request (e.g., for an issue with delivery handled by the clinic, issue with CD quality/condition).
• Name:
• Address:
• Support Phone:
• Support Email:

Healthcare Provider Logo

• Email a copy of the Healthcare Provider’s logo as an image file to smanske@e-requestllc.com. The logo will be displayed on invoices and retrieval-related documents.