Medical Records (ROI) Set-up Form - eRequest LLC

Medical Records (ROI) Set-up Form

Your Contact Information
Provider Identity
  • *
  • *
Patient Fees
  • Enter processing fee to be charged for patient requests for medical records. Enter "NA" if an item does not apply.

Turnaround Times
  • Enter processing turnaround time in hours or days. Do not factor in any non-web delivery timeframes here.
Processing Responsibility
  • Indicate if "Service Company" or "Provider" will process the PHI for the following categories.

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.

Delivery Responsibility to Patients
  • Which patient-specific delivery methods will the Provider be solely responsible for?

Release Restrictions
  • In the Provider’s state, what is the age of majority for patients to request their own medical records?
  • 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.

Provider Locations Using TRIMSNet
Contact for Provider Medical Records Management
  • Enter contact information for provider’s HIM/practice manager.
Contact for Provider IT
  • Enter contact information for person/company responsible for Provider IT.
Contact for Provider Website Modification
  • Enter contact information for person/company responsible for editing provider’s website, if applicable.
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).
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.