Medical Records Release Form printable pdf download

EDIATRIC

SSOCIATES OF

LEXANDRIA

Medical Records Release Form

Authorization for the Release of Protected Health Information

I hereby authorize the use or disclosure of my child(ren)’s individually identifiable health information as

described below. I understand that if the organization authorized to receive the information is not a health

plan or health care provider; the released information may no longer be protected by federal privacy

regulations. There will be a fee for the requested records. Please allow a minimum of 1-2 weeks for

processing.

**PATIENT 18 YEARS OF AGE ARE CONSIDERED ADULTS AND THEREFORE MUST REQUEST THEIR OWN

MEDICAL RECORDS***

Name: ____________________________________ DOB: ____/____/____

** We strongly recommend records be sent to parents; if we should have to re-print your child’s

records there may be an additional fee.

Providing Information:

Mailing Address:

Pediatric Associates of Alexandria

Name:_____________________________

6355 Walker Lane Suite 401

Address: ___________________________

Alexandria, VA 22310

City, State, Zip:______________________

Phone: 703-924-2100 ext. 202

Phone: ___________________________

Fax: 703-922-6067

***Records will not be faxed.

Specific Description of the Information to be Disclosed:





All Medical Records

Specific dates of service, from: ____ /_____/____ to ___ /____/_____





records were brought from another medical office, would you like to receive a copy of these records? Yes____ No____

All Records-Fee:

$0.50 per page for the first 50 pages; $.0.25 a page for each additional page.



I would like my child’s records mailed. I understand there is an additional $10.00 handling/mailing fee.



I will pick up my child’s records



Digital Copy of Records ($25.00 for first record. $15.00 per additional sibling. Postage included in price).

Reason for Release:

Relocating ____/_____/____

Change Doctors

 Other, Not Transferring ____________________________

I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. I understand that I have the right to refuse to sign this

auth.orization. In the event I refuse to authorize the release of the above-described information, I understand that it will not be disclosed, except as provided by law. I understand that

the practice may not condition treatment on whether I sign this authorization, except when the provision of health care is solely for the purpose of creating protected health information

for disclosure to a third party. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be

protected by law.

I understand that this authorization is valid until it expires, unless revoked before that. I understand that I may revoke this authorization at any time by giving written notice to the

physician of my desire to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health

information. Written revocation must be sent to the physician’s office to the attention of the Privacy Officer. Absent such written revocation, this Authorization Form for Release of

Protected Health Information will expire in 2-years from the date initiated below.

___________________________________________________

_____________

Signature of Parent, Patient or Guardian

Date

____________________________________________________

_____________

__________________

Printed Name of Parent, Patient or Guardian

Relationship

Phone Number