Release Form Of Medical Records To Pediatric Health Care Alliance, Pa printable pdf download

Release Form Of Medical Records To Pediatric Health Care Alliance, Pa

Office Information

Release of Medical Records to

Pediatric Health Care Alliance, PA

Please request to speak to the Records Clerk for

questions or additional information.

Patient Name (Print):

Patient DOB

Patient Name (Print):

Patient DOB

Patient Name (Print):

Patient DOB

Patient Name (Print):

Patient DOB

Patient Name (Print):

Patient DOB

Doctor/ Facility Name: _______________________________________________________________________________________

Address: _________________________________________________________________________________________________

Phone: ___________________________________________

Fax: _______________________________________________

______ I understand the information in my health record may include information relating to 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.

______ I understand once the information below is released, it may be re-disclosed by the recipient and the information may not be

protected by federal privacy laws or regulations.

______ I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in

writing and present my written revocation to the practice. I understand the revocation will not apply to information that has

already been released in response to this authorization. I understand the revocation will apply to my insurance company when

the law provides my insurer with the right to contest a claim under my policy.

______ I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure health care

treatment.

This authorization will expire on (insert date or event):

If I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it was signed.

Patient Signature (or Signature of Person Completing Form if Not Patient)

Date

Relationship to Patient

Parent

Legal Guardian

Other:

Witness Signature

Date

Release Form Of Medical Records To Pediatric Health Care Alliance, Pa