Medical Records Request - University Place Pediatric Clinic printable pdf download

P hone: (253) 564-1115

Bruce G. Davies, M.D., F.A.A.P .

Paul E. DeBusschere, M.D., F.A.A.P .

Fax: (253) 565-4552

John M. Hautala, M.D., F.A.A.P .

Michelle H. Ost, M.D., F.A.A.P.

1033 Regents Blvd., Suite 102

Belinda S. Rone, M.D., F.A.A.P .

Megan Struthers, M.D., F.A.A.P .

Fircrest, W A 98466

HIPPA Authorization for Records Release of Health Care Information

***Incomplete forms will not be processed***

PATIENT INFORMATION: Doctor:

Davies

DeBusschere

Hautala

Ost

Rone

Struthers

__________________________________________________________________ DOB: _______________________

(PRINT) First Name

Middle Initial

Last Name

_______________________________________________________________________________________________

Address

City

State/Zip

Phone

Check appropriate box and give complete name and address information:

Name: _______________________________________________________________

To receive records from

Address: _____________________________________________________________

To verbally exchange with

City/State: ____________________________________________________________

Phone: ___________________________ Fax: _______________________________

INFORMATION TO BE RELEASED:

Vaccine Record

Problem List

Medication List

Growth Chart

Last year of Chart Notes and Lab Results Dated: ________________________ to _________________________

Health care information in my medical record relating to the following treatment or condition:

___________________________________________________________________________________________

Medical Records from ____________________________________ to ___________________________________

Specific Information (please specify): _____________________________________________________________

PATIENT AUTHORIZATION:

I understand that my records may contain information regarding the diagnosis or treatment of mental illness, psychiatric treatment, drug and/or alcohol

abuse, HIV/AIDS, or sexually transmitted diseases. I give my specific authorization for these records to be released. I UNDERSTAND MY RIGHTS LISTED

BELOW.

______________________________________________________

Signature of Patient if over 13 years of age

] To EXCLUDE any of the following information from the records to be released please initial:

Mental Illness or Psychiatric diagnosis/treatment _______

Drug Alcohol abuse/treatment & diagnosis _______

HIV/AIDS diagnosis/treatment/testing _______

Sexually transmitted diseases _______

My Rights:

I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment.) I may revoke this authorization

in writing. To view the process of revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is

being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization

may re-disclose it, at which time it may no longer be protected under Privacy Laws.

__________________________________________________________________________________

________________________________

Signature of Parent or Legal Guardian/Representative

Date

This authorization shall remain in effect unless revoked in writing.

A copy of this authorization shall have the same force and effect as the signed original.

uppcRR-NP 06/15

RECORDS RELEASE - NEW PATIENT