Document request consent form – San Fernando Pediatrics and Urgent Care

Which document are you requesting? *

Please clarify *

*When your results are ready, they are available for pick up right away. We will be able to email or fax your results to you by the end of next business day. Some test results are restricted and must be picked up in person.

**For self-pay patients, itemized receipts are available in 2 to 4 weeks. While payment receipts are provided at the time of service.

**There are no itemized receipts for patients using insurance, instead you will receive an EOB in the mail directly from your insurance provider after they process the claim. Payment receipts are provided on the day of service for any copayments paid.

**If you paid using our online payment link, your receipt has automatically been sent to your email. If for some reason you have lost that email, please allow 2 to 4 weeks for your receipt to be emailed to you.

**If you paid cash, your receipt was available at the time of service. If you are requesting for a copy of your receipt, please allow 2 to 4 weeks for your receipt to be emailed to you.

How would you like to receive your requested document? *

Which test results are you asking for? *

Which COVID-19 TEST DID YOU DO? *

BLOOD ANTIBODIES
NASAL SWAB PCR
NASAL SWAB RAPID ANTIGEN

Your TEST DATE *

Your RECEIPT DATE *

Patient's Full Name *

First

Last

Patient's Date of Birth *

Patient's Phone Number *

Email *

Email

Confirm Email

Fax Number *

Who will pick up the documents on your behalf? *

First

Last

Their DOB *

I give consent and request that the clinic provide my documents to the person above. *

YES

Please read and click to acknowledge the following:

1. Test results will be sent out at the end of the next business day, when they are available.

2. Itemized receipts will be sent out in 2 to 4 weeks.

3. The information you provided is accurate and signed voluntarily.

4. Please check your email spam folder.

5. Please submit only ONE form per request.

I have read and acknowledge *

YES

I give consent and request to receive the above document(s) from San Fernando Pediatrics & Urgent Care, which may include my test results, and other protected health records. I request the above mentioned documents to be sent in the email address or text message noted on this consent form. I understand that email and/or text are NOT secure forms of communication and my protected health information maybe put at risk of breach of data. By signing this consent form, I take full responsibility and will not hold San Fernando Pediatrics & Urgent Care or their representatives responsible for any breach of data. I understand that I have the option to receive these documents in person or by fax, which are considered secured forms of communication. *

Signature of patient or legal guardian

I give consent and request to receive the above document(s) from San Fernando Pediatrics & Urgent Care, which may include my test results, and other protected health records to be provided to the person named above. I take full responsibility and do not hold San Fernando Pediatrics & Urgent Care or their representatives responsible for any breach of data or loss of privacy as a result of this request. I understand that I have the option to receive these documents in person or by fax, which are considered more secured forms of communication. *

Signature of patient or legal guardian

Comment (optional)

How would you rate your experience completing this form online? *

How can we improve? *

Please let us know how we can do better