Sent by St. Mark's Family Medicine

Hi, there

Before your visit with your provider on your appointment, we'd like to gather your prior medical records.

First, let's verify it's really you.

Confirm your date of birth

Phone

By providing your mobile number, you agree to receive appointment and intake text messages from your clinic via Ownity. Msg & data rates may apply. Reply STOP to opt out, HELP for help.

Home address

These are optional. Skip any field you'd rather not share — your clinic can fill them in at check-in.

Authorize your records

HIPAA requires your written permission before other clinics can send us your records. This only takes a moment.

Authorization for Release of Protected Health Information

Patient: the patient Date of birth: — Authorized recipient: your clinic

1. Purpose & scope. I, the patient, authorize my current and prior healthcare providers, hospitals, laboratories, imaging centers, pharmacies, and health plans to disclose my protected health information (PHI) to your clinic ("the Clinic") and its authorized agents, including Ownity, Inc. (“Ownity”), for the purpose of treatment, care coordination, and continuity of care.

2. Information covered. This authorization applies to my medical record, including but not limited to: office and visit notes, history and physical exams, laboratory and pathology results, diagnostic imaging reports, medication and prescription history, problem and allergy lists, immunization records, discharge summaries, and consultation reports.

3. Electronic network retrieval. I authorize the Clinic and Ownity to electronically locate and retrieve my existing medical records from my other providers and from connected health information networks (including Carequality and CommonWell) on my behalf, for my care. This item is optional — I may decline it below without affecting my care.

4. Specially protected records. Records that receive special protection under federal or state law — including psychotherapy notes, substance use disorder treatment records (42 CFR Part 2), HIV/AIDS, genetic information, and reproductive health — are not released under this general authorization and require separate, specific written consent.

5. Re-disclosure. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may then no longer be protected by federal privacy law. The Clinic and Ownity will not sell my information or use it for marketing.

6. Expiration. This authorization expires 90 days from the date of signature, or on any earlier date or event I specify, unless I revoke it sooner.

7. Right to revoke. I may revoke this authorization at any time by submitting a written request to the Clinic. Revocation will not apply to information already disclosed in reliance on this authorization.

8. Voluntary. Signing this authorization is voluntary. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign, except where the law permits.

9. Copy. I am entitled to a copy of this signed authorization.

By signing below, I certify that I have read and understand this authorization, that I am the patient named above (or that patient's authorized personal representative), and that the information I have provided is true.

— End of authorization —

Please scroll to the end of the document to enable signing.

I have read and I authorize the release of my records as described above. Retrieve my records from other providers automatically so my care team has my full history. (Optional — uncheck to decline.)

Type your full name to sign

Date of signature: —

🔒 Your information is encrypted and HIPAA-compliant. Ownity Health is a care-coordination platform trusted by clinics nationwide.

Good morning, John

Here's what's happening today

Requests

Outbound

Inbound

Inbox

Inbound faxes auto-routed to the right provider. Anything we couldn't match shows below — one click to assign.

To-Do

Your action list, prioritized — work top to bottom

Detail

Import Schedule

Get your appointments into Ownity so records workups start automatically.

Upload CSV

✏ Paste

✉ Email forwarding

⚙ EMR auto-sync

Export tomorrow's schedule from your EMR or scheduler as a CSV, then drop it here. We auto-detect columns by header name — first/last (or "Name"), DOB, MRN, appointment date/time, provider, reason, phone, email. Anything we can't map is shown for you to confirm.

↓

Drop a CSV here or click to browse

.csv files only · up to a few thousand rows at a time

Send Records Request

Print the fax cover or copy the email body, then send through your existing fax/email tool.

✉ Email

📠 Fax Cover

Ownity Health <[email protected]>

Medical Record Request — Patient Name

To: Records Department • [email protected]

Just now

ownityhealth.com [email protected]

Medical Record Request • HIPAA-Compliant

Requesting Clinic

Your Clinic

Medical Record Request — Patient

Message body

Records Requested

✓ Full Record Set

🔒 HIPAA Authorization Attached

A signed HIPAA-compliant release is enclosed. Return records via the secure upload link below.

⇧ Upload Records Securely

Encrypted • HIPAA-compliant • No login needed

Sent via Ownity • HIPAA-compliant • Encrypted

ownityhealth.com [email protected]

Is your clinic still managing records manually?

Ownity automates requests, follow-ups & secure document exchange.

Book a Demo →

CONFIDENTIALITY NOTICE: This email contains protected health information intended solely for the named recipient. If received in error, please destroy and notify [email protected].

Done

HIPAA Authorization

✓ Signed electronically • Ref:

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Pursuant to 45 CFR §164.508 (HIPAA)

Patient Information

Full Legal Name

—

Date of Birth

—

Insurance Provider

—

MRN

—

Authorization

I authorize my healthcare provider and any prior treating physicians, hospitals, clinics, or health plans to disclose my protected health information to:

Requesting Organization

Ownity, Inc. / Requesting Clinic

records@ownityhealth.com • (800) 555-0190

Purpose: Continuity of care — to obtain prior medical records in advance of an upcoming appointment on —.

Records authorized for release:

✓ Office visit notes ✓ Lab results ✓ Imaging & radiology ✓ Medication history ✓ Procedure reports ✓ Specialist referrals

Patient Rights

• I understand I may revoke this authorization at any time by contacting Ownity, Inc. in writing, except where action has already been taken in reliance on this authorization.

• I understand that signing this authorization is voluntary and that my treatment is not conditioned upon signing.

• I understand that information disclosed may be subject to re-disclosure and no longer protected by HIPAA.

• This authorization expires one year from the date of signature or upon fulfillment of the records request, whichever comes first.

Electronic Signature

Patient Signature

—

Date Signed

—

Signed Via

E-signature • Ownity intake portal

IP Address

192.168.1.42

This authorization was collected in compliance with 45 CFR §164.508 of the Health Insurance Portability and Accountability Act (HIPAA). A copy of this signed authorization has been provided to the patient and is retained on file by Ownity, Inc.

✦

Ownity Found Additional Records

While processing records from , Ownity identified provider(s) not yet in ’s request list.

Discovered by analyzing incoming record references • Review before sending

Hi, there

Authorize your records

Where have you been seen?

Front of your insurance card

Now flip your card over

You're all set!

Good morning, John

Requests

Inbox

To-Do

Insurance auto-verification

Detail

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Hi, there

Authorize your records

Where have you been seen?

Front of your insurance card

Now flip your card over

You're all set!

Good morning, John

Requests

Inbox

To-Do

Add Quick Link

Send a fax

Add records

📅 Schedule Patient

📅 Schedule Patient

Confirm with Patient

✓ All Set

Insurance auto-verification

Intake Form

Detail

New Record Request

+ Create New Patient

Add Clinic

Paste a list of clinics

New Referral

Connect your EMR

Send Records — Patient

Quick Actions

Add Provider

Invite User

Invite ready

New Patient

Edit Care Team

Send Intake Link

Send Intake Link

Insurance Update Reminders

Bulk Eligibility Verification

Log Eligibility Check

Import Schedule

Edit Patient Info

Edit Insurance

Decline Inbound Request

Decline & Redirect Referral

✦ AI Auto-Configure

AI Recommendation

🔒 HIPAA Audit Log Requirements

Referral Auto Follow-up

Add Widget

Send Records Request

Sent records

Send Records

Records sent

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Follow-up Settings

Follow-up

Records Discovery

Preview

Prior Providers

Ownity Intake

🧪 Inject test fax

✉️ Inject test scheduling email

✉ Match email to referral

✉ Email source

Patient address

Document

⚠ Verify at intake

📅 Mark Scheduled