Medical Records Request Form For Treatment Purposes printable pdf download

Medical Records Request Form For Treatment Purposes

From: Another Facility

To: Summit Pediatrics

Fill out this form and send to your child’s previous doctor

Date: _____________

To: _____________________________

_______________

____________________

Practice/Doctor name

office phone

office fax

_____________________________

Street Address

_____________________________

City, State and Zip

Please forward copies of medical records on the patients named below to:

Summit Pediatrics

F. Clark Cantrell, MD

707 Whitlock Avenue/Ste. F-2

Marietta, GA 30064

(P) 770-943-9150 /(F) 877-347-4158

Patient Name

Date of Birth

______________________________

_________________

Signature of Patient/Parent/Guardian

Printed Name

HIPPA Notice:

According to HIPAA guidelines, patient consent or authorization is not required for

transfer of records for treatment purposes.

A HIPAA-specific request is not required, since not even

the patient’s permission is required.

The Privacy Regulation specifically states that a covered entity

“is permitted to use or disclose protected health information” for “treatment, payment, or health care

operations,” without patient consent. As HHS explains, “treatment” includes “consultation between

health care providers regarding a patient and referral of a patient by one provider to another.” HHS

further states that providing health records to another health care provider for treatment purposes

“can be done by fax or other means.” §§164.502(a)(1)(ii), 164.506(a),

Medical Records Request Form For Treatment Purposes