Corridor Primary Care Pediatrics Request For Release Of Medical Records Form printable pdf download

Corridor Primary Care Pediatrics Request For Release Of Medical Records Form

CORRIDOR PRIMARY CARE PEDIATRICS

601B Leah Ave

San Marcos, Texas 78666

PHONE: (512) 392-1700 FAX: (512) 396-8743

REQUEST FOR RELEASE OF MEDICAL RECORDS

Patients Name:____________________________ DOB: ____________

I understand that my/my child’s medical records are confidential and cannot be disclosed

without my written authorization, except otherwise provided for by law. I hereby

voluntarily authorize the health information regarding the above named person to be

exchanged between

From: _____________________________

To: __________________________

Address: ___________________________

Address: ______________________

City/State/Zip: _______________________

City/State/Zip: _________________

The specific purpose(s) for this disclosure is/are:

Phone:__________________

( ) My personal Use

Fax:________________

( ) Sharing with other Healthcare provider

( ) Other (Specify) _________________________________________________

( ) I want ( ) do not want you to include information pertaining to the diagnosis and /or

treatment of HIV testing, AIDS, psychiatric illness, and alcohol or chemical abuse or

dependency if any.

Specific Information to be released: (Please check all that apply)

___Complete Medical Record

___Immunization record only

___Lab/X-ray

____History & Physicals

____Progress note

____D/C Summary

____Other ______________________________________

I understand that I may revoke this authorization at any time by notifying the office in

writing.

I understand this authorization expires 180 days from the date signed unless otherwise

revoked.

I understand that once the above information is disclosed it may be re disclosed by the

recipient and the information may not be protected by federal privacy laws or regulations.

I understand that a photocopy or facsimile of this authorization is as valid as the original.

__________________

__________________________________________

Date

Signature of patient, parent or authorized guardian

__________________________________________

Print Name

Corridor Primary Care Pediatrics Request For Release Of Medical Records Form

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