Please print and complete the new patient packet. To complete your registration, we will need a picture of your photo ID and Insurance Card if you have one. Please fax or email the completed forms and cards to our Care Connection Team:
Secure fax- 888-530-3638
Email- careconnectionteam@cancommunityhealth.org
If you are unable to complete these forms prior to your visit, please arrive at least 15 minutes in advance of your appointment to complete them in our office. Thank you again for choosing CAN Community Health to provide your care. Please click here for download and email instructions
Please Click here to Download the New Patient Forms
Haga Clic aquí para ver los Formularios para Pacientes Nuevos en Español
Requesting Copies of Your Personal Medical Record or for Your Records to be Sent to Another Facility
Verisma Portal
Patients may request their medical records via the Verisma Portal. You may also obtain a copy of your medical records by printing and completing the Authorization to Disclose Confidential Information form below. The completed request should be mailed or hand-delivered to a CAN Community Health clinic.
You may submit your request for records via fax to 866-800-6131
FAQs
Is there a charge for medical records?
- There is no charge for records released directly to a patient
- There is no charge for records released directly to a verifed physicians office
- All request for records from third-party requesters will be charged a fee for copying of medical records. The fee is determined based on individual state statues. For status updates, please contact Verisma Customer Service at 866-837-5550.
Can I have my medical records emailed to me?
- Yes, the email containing the attached records will be encrypted. Instructions on how to open a CAN Community Health Encrypted Email will be sent separately. Please note: The email address you receive the records from is intended to be used to assist in request of medical records. Please do not respond to the email address to schedule/change appointment or for questions regarding your care. Please contact the office directly, or 844-922-2777.
There is a mistake in my record, how do I request a correction?
- Patients who request to amend their record must complete the Request to Amend Health Care Information form and submit to CAN Health Information Management either via e-mail at HIMTeam@cancommunityhealth.org or via mail at the address below. For more information about requesting amendments/corrections to your medical record, please call 941-300-4440.
CAN Community Health
c/o HIM Amendment
2105 N. Nebraska Ave
Tampa, FL 33602
What is CAN's Privacy Policy?
When it comes to your health information, you have certain rights. Your Information. Your Rights. Our Responsibilities. Please review CAN Community Health's Notice of Privacy Practices.
Notice of Privacy Practices
Notificacion de Practicas de Privacidad
We work hard every day to provide the highest quality and most caring service to our visitors. We care about your experience in our clinics. If for any reason you would like to file a formal complaint please follow this Grievance Procedure:
Grievance Procedure
