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The Washington Endocrine Clinic Medical Records Release Form

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Michael J. West, M.D., Ph.D.

Board Certiﬁed in Endocrinology, Diabetes and Metabolism

Treyce S. Knee, M.D.

Board Certiﬁed in Endocrinology, Diabetes and Metabolism

Donna Westervelt, MS, CRNP, CDE

Diabetologist

Tammy Peng, RD, LD

Registered Dietitian

MEDICAL RECORDS RELEASE FORM

Patient's Name: _____________________________________________ Date of Birth: _______________

Patient's current address: ______________________________________________________________________

Person(s) or medical provider(s) to whom protected health information (PHI) should be released:

Name:

________________________________________________________________________

Address:

________________________________________________________________________

How do you want the records released?

Fax to the following number: ____________________________.

Hard Copy – mailed to the address you provide above.

E-mail – HIPAA laws (according to the “Final Rule” update to HIPAA laws) now allow for medical records to be

e-mailed. However, by checking this box you signify that you understand and accept that the e-mail sent

will be unencrypted and you will assume any and all risk associated with sending unencrypted e-mails.

E-mail address to use: _______________________________________________________.

Cost for this release request (This form will not be processed if this box is not checked.)

I understand that HIPAA laws allow for the Clinic to charge a patient a reasonable fee for the right to access

protected health information. These fee include for such items as the cost of copying, supplies, labor, and

postage. Unlike the other 50 states in the US, the District of Columbia does not regulate these costs. The

Clinic sets these costs based upon an examination of other state laws. The current charge is $1.50 per page

for the ﬁrst 10 pages, and then $0.75 for pages 11-500. These cost limits apply to both electronic and paper

copies.

Time frame to process request (This form will not be processed if this box is not checked.)

I understand that HIPAA laws allow a processing time of up to 30 days to process a request for medical

records. However, the Clinic tries to complete this process within 3-5 business days after receipt of this form.

2440 M Street, NW ▪ Suite 417 ▪ Washington, D.C. 20037

Phone 202-570-5151 ▪ Fax 202-446-2946

▪

The Washington Endocrine Clinic Medical Records Release Form

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