Hipaa Form B - Pediatric Associates Request To Release, Copy, Or Inspect Protected Health Information
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1HIPAA – FORM B
PEDIATRIC ASSOCIATES
R
R
, C
,
I
P
H
I
EQUEST TO
ELEASE
OPY
OR
NSPECT
ROTECTED
EALTH
NFORMATION
Patient Name: _________________________________________ Date of Birth:__________________________________
Patient Address: ________________________________________
Account /Chart: ________________________________
Street
________________________________________ Phone # ____________________________________
City, State, Zip
For Record Release or Copies: By signing this authorization, I authorize the party listed below to use and/or disclose certain
protected health information (PHI) about me / my child. I also understand that I may revoke this authorization at any time, in
writing, to the address listed below provided the information has not been released.
This authorization permits:
______________________________ to use or disclose to _____________________________________________________
Provider’s Name
New Provider, Specialist, or Person Receiving Copy
______________________________
____________________________________________________
Street Address
Street Address
______________________________
____________________________________________________
City, State, ZIP
City, State, ZIP
______________________________
____________________________________________________
Phone #
Phone #
Information to be Released / Copied: ( ) All pertinent medical records including immunizations and lab tests
( ) Day sheets – dates: ________________________
( ) Lab Info - dates:___________________________________
( ) Other: __________________________________________________________________________________________
Information to be Excluded / Not Released: ( ) Mental Health Records
( ) Drug/Alcohol Treatment
( ) HIV Testing
( ) Sexual Assault/Victimization Records
( ) Other: ______________________________________
*** BE SURE TO REVIEW ANY RESTRICTIONS PRIOR TO COPYING / RELEASING ***
Reason for Record Release or Copy:
( ) Personal copy <see below / charges apply>
( ) Over age 21 ( ) Insurance change ( ) Moving / Changing providers ( ) Referral to Specialist
( ) Unhappy with Practice (Please state why) ______________________________________________________________
( ) Other: __________________________________________________________________________________________
For Patient or Guardian Inspection / Paper or Electronic Copy Requests: ( ) Paper ( ) Electronic
I understand and agree that I am financially responsible for the following fees associated with my request: copying charges,
including the cost of supplies, electronic devices, labor, and postage related to the production of my information. I understand
that the charge for paper copy is: $1.00 each page for the first 25 pages, then $.25 for each page thereafter. If requesting
an electronic copy, the charge is $20 which covers the cost of an encrypted CD.
__________________________________
________________________________________________________________
Signature of Patient or Legal Guardian
Date*
*Inspection requests are valid on the date of signature only
__________________________________________
*Release/Copy requests expire 30 days from signature date
Print Name of Patient or Legal Guardian
for paper copies and expire 3 business days from signature date for electronic
copies
Prohibition of Re-disclosure: This information has been disclosed to you from records whose confidentiality is protected by law. Any further disclosure is
strictly prohibited unless the patient/guardian provides specific written consent for subsequent disclosure of this information. These records may be protected
by federal regulation (42 CFR, Part 2).
FOR INTERNAL PURPOSES ONLY: Name & Title of Person Releasing Records ______________________________________________
Method of Transfer: О Mailed on (date) ________________________ Certified ? (certification #) ___________________________________
О Faxed to (number) _________________________________________ on (date) ______________________________________
О Picked up by (name) ________________________________________ on (date) ______________________________________
О YES О NO
Verification of Identification Performed?
Form of Identification: _______________________________________
FORM B 2/03, rev. 4/03, 10/03, 1/04, 4/04, 1/05, 8/05, 9/13, 12/13, 05/14
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Parent category: Medical