Medical Records Release Form printable pdf download

PEDIATRICS SOUTH

MEDICAL RECORDS RELEASE FORM

Patient Name_________________________________________ Date of Birth________________

Address_________________________________ City/State/Zip_____________________________

I, the undersigned, authorize Pediatrics South to release the protected health information for

the patient named above to:

Person or Facility: _________________________________________________________________________

Address: __________________________________________________________________________________

City, State, Zip: ___________________________________________________________________________

□ Please mail records

□ Please fax records – fax number: ___________________

□ Email – email address: _____________________________

Dates and Type of information to release:

□ 2 years prior from last date seen

□ Specific Dates: _____________________________________________________________

□ Specific Information: ________________________________________________________

RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise

requested. I understand the information in my health record may include information relating to sexual history/sexually

transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include

information about behavioral or mental health services, and treatment for alcohol and drug abuse. The records will be

provided unless I specify that the following information should NOT be released: _______________________________

I understand that this Authorization is effective for a period of 90 days from the date of the signature, unless otherwise

specified below. No time frame may exceed one year from the date of signature. I understand that I have the right to revoke

this authorization at any time by sending a written request to the entity/person I authorized above to release the information.

I understand that if the person or entity that receives the above information is not a healthcare provider or health plan covered

by federal privacy regulations, the information described above may be re-disclosed by such person or entity and will likely

no longer be protected by the federal privacy regulations

. THERE MAY BE FEES ASSOCIATED WITH THIS REQUEST AS ALLOWED

BY THE COMMONWEALTH OF PENNSYLVANIA.

Patient/Parent/Legal Guardian Signature: ___________________________________________________ Date: ____________

Relationship to Patient: _______________________________________________________

(Legal Guardian may be required to attach supporting legal documentation)

Patient Signature: ____________________________________ ____________________________________ Date: ____________

(If patient is a minor (between the ages 14-18) he/she must sign for Release of any Restricted Health Information)

RECORDS WILL BE COMPLETED WITHIN 30 DAYS OF RECEIPT OF COMPLETED RELEASE FORM. (60 DAYS IF RECORDS ARE OFF-SITE.)

Medical Records Release Form