Records Release Form - Pediatric Healthcare

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46440 Benedict Drive, Suite 207
224-D Cornwall Street NW Suite 104
Sterling, VA 20164-6602
Leesburg, VA 20176
Phone (703) 444-2100
Phone (703) 779-0699
Fax (703) 444-0386
Fax (703) 779-7712
Completed Request Forms May Be Returned by Fax.
AUTHORIZATION FOR RELEASE OF INFORMATION
PATIENT NAME: ____________________________________ D.O.B.__________________
PATIENT NAME: ____________________________________ D.O.B.__________________
PATIENT NAME: ____________________________________ D.O.B.__________________
PATIENT NAME: ____________________________________ D.O.B.__________________
I declare that I am the parent/legal guardian of the above named patient(s), and hereby request and authorize
Pediatric Healthcare, P.C. to release copies of their medical records, including diagnosis, treatments, prognosis,
recommendations, and other data to include insurance information. Lab, radiology, specialist reports or any other
information from other providers regarding the patient and in our possession may be copied and released.
I am aware that records may contain HIV/AIDS results, sexually transmitted disease, reproductive health,
alcohol/drug abuse, child or adult abuse and mental health information and consent to their release.
Initial: ________ Date: _____________
SELECT FROM THE FOLLOWING:
1. ___________I request ALL of the medical records for each patient.
2. ___________I request records from the following dates: ________________ to ___________________.
3. ___________Other, please specify: ______________________________________________________.
Fees for Records Copying
The cost of supplies and a copy preparation fee as allowable by Virginia’s Health Records Privacy statute 32.1-
127.1:03 J will apply. This fee is determined by a per page fee plus labor and if applicable postage. You will be
notified by phone when copying is complete and of the total cost.
Please allow fifteen (15) business days to process your request. You will be notified by phone when copying is
complete and the records are ready for pick up. You may be required to present proof of identity when picking
up records. Records will only be mailed if you are moving out of the area, and then will only be mailed
DIRECTLY TO YOU for confidentiality and security reasons.
Parent/Guardian Name_________________________________________________________________
Address_____________________________________________________________________________
Daytime Phone Number________________________________________________________________
Purpose of Disclosure:
Moving Out of Area _______ Changing Doctors _______ Switch to Adult Physician ___________
Insurance Change
_______ Referral to Specialist _____ Legal Purposes ____________________
Disability Determination____ Other (please specify) ______________________________________
Your signature authorizes the release of your/your child’s medical records and constitutes your consent to pay
Pediatric Healthcare, P.C. for fees as billed.
Signature (required)
Date (required)
10/07

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