Netcare Secure File Transfer

NOTE: THIS IS NOT AN AUTHORIZATION FOR RELEASE OF INFORMATION FORM!!!

INSTRUCTIONS:

1. If you do NOT have a completed ROI form, please complete and submit the Secure File Transfer form. Medical Records staff will contact you with instructions on how to obtain records, including a link to complete an online ROI form.

2. If you DO have a completed ROI form, complete the Secure File Transfer form and attach the ROI to submit along with this form.

3. Patients/Clients requesting records must attach a copy of their current photo ID for identity verification purposes.

Your name

Email address

Phone number

Patient name

Company / Organization (if applicable)

Intended recipient (to whom is information to be sent)

Comments

Files You can add multiple files

Add file

Please upload a file

Your information will be encrypted.

Netcare Secure File Transfer

INSTRUCTIONS:

Netcare Corporation