Clinical Trial Patient Medical Records Request Form

Request access to your clinical trial medical records easily with our secure online form. At Top One Research Group, we prioritize your privacy and ensure compliance with HIPAA regulations. Submit your request today, and our team will guide you through the process swiftly and securely.

Clinical Trial Patient Medical Records Request Form

Contact Person:

Gueylin Gongora

Research Site Name:

Palm Beach Research Clinic DBA

Top One Research Group

Main Number:

(561) 249-6180 ext.1

Position:

Lead Study Coordinator, Clin Ops and Lab

Email CRC: ggsupport@toponeresearchgroup.com

Email Project Manager: wmuro@toponeresearchgroup.com

Address: 4698 Forest Hill Blvd, Suite B, West Palm Beach FL 33415

Facility Releasing Information:

Facility name

Phone

Fax

Patient Information:

First name

Last name

Phone

Date of Birth (DOB):

Month

Day

Year

Address

On behalf of Palm Beach Research Clinic DBA Top One Research Group, I request access to the medical records of the above-named patient for clinical research as per the approved study protocol. By signing, I agree to:

Regulatory Compliance: Actions will comply with federal, state, and local laws, including HIPAA, FDA, and ICH-GCP guidelines, and any other applicable regulations.
Confidentiality: Patient information will be kept confidential, stored securely, and handled in line with privacy laws. No identifiable information will be shared without authorization.
Revocation Rights: The patient can revoke this authorization anytime by submitting a written request to Palm Beach Research Clinic DBA Top One Research Group.

Purpose: I authorize the release of my health information for the following specific purpose:

(Note: “At the request of the patient” is sufficient if the patient is initiating this authorization)

Information to be disclosed: I authorize the release of the following health information: (check the applicable box bellow)

All of my health information that the provider has in his/her possession.

Only the following records of type of health information

Patient’s Full Name

Research Site Name

Patient’s Signature

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Research Site’s Signature

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Date

How to Request Your Medical Records

Complete the Request Form

Fill out our secure online form with your personal information and study details to begin the request process.

Verify Your Identity

For your protection, we verify your identity before processing your medical records request. You will receive an email with verification instructions.