Record Release Form printable pdf download

Record Release Form

Lockman & Lubell Pediatric Associates, LLC

Record Release Form

Patient's Name: ____________________________

DOB:

_________________Name

Address: _________________________

_________________________

Phone Number: __________________

Address:

THE UNDERSIGNED AUTHORIZES THE RELEASE OF MEDICAL RECORDS

TO:

Name: ____________________________________

Address: _________________________

Address:

_________________________

For the Purpose of: __________________________________________

Type of Information Requested:

___________________________________________

I authorize the above named source to release or disclose the following

information: Any medical records or other information regarding my treatment,

hospitalization, and/or outpatient care for my condition(s), including psychological

or psychiatric condition(s), alcohol and/or drug abuse, or any HIV-related

information; (in accordance with Federal confidentiality rules (42 CFR Part 2),

State Mental Health Procedures Act and ACT 148).

If there are any limitations to this list of information, please specify:

I understand this consent can be revoked at any time except to the extent that

disclosure has already occurred in reliance on this request. Otherwise this

authorization shall remain in effect for the period of 90 days from the date of my

signature.

________________________________________________

_________

Signature of Patient/ Legal Guardian/ Legal Representative

Date

Relationship to Patient ______________________________

There is a $35.00 fee for record releases.

Record Release Form