Form Phc-Mr091 - Authorization For The Release Of Health Records Page 3

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Authorization Instructions: Release of Health Records
Please note: We will return your authorization form to you if you have not completed all
required parts.
Step 1: Complete the Following Parts on the Authorization Form
Part 1: Fill out this part completely.
Part 2: Check all the boxes corresponding to the records you would like. If you do not know
the exact date(s) of the records you are requesting, provide your best estimate.
Part 3: Fill out this part completely. Please include a daytime telephone number and a return
address at which you can be reached, as we may need to contact you to properly process your
authorization form.
Part 4: If you are the patient requesting your own records and are 12 years of age or older,
you must sign and date this part.
Please Note: Parents/guardians, if your child is over 12 years of age, your child MUST
sign the authorization form to obtain their records.
Part 5: If the patient is a child under 12 years of age or otherwise unable to consent (e.g.,
mentally incompetent, deceased), you must complete this section in full, including the reason
for your request. If you require more space, please attach an additional sheet of paper to your
authorization form. Please include any documentation supporting your request.
1. If your child is under the age of 12 years, you may be asked to provide supporting
documentation proving you are a guardian. Acceptable supporting
documentation would include, but is not limited to, a letter from a lawyer, school
teacher, or a doctor stating that they have knowledge that you are a guardian.
Please note that Section 40 of the Family Law Act states that a child’s guardian may
exercise all guardian responsibilities as long as they do so in consultation with the
child’s other guardian(s), unless consultation would be unreasonable or inappropriate in
the circumstances.
Please Note: If you are requesting the records of a deceased patient, you MUST ensure
that your authorization form also includes the following:
2. A copy of the deceased patient’s will, letters probate, or letters of administration naming
you (or the requestor) as the deceased patient’s representative.


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