Request / Transfer of Medical Records

The purpose of this form is to obtain authorization for use or release of protected health care information. Patients have the right to receive one free copy of their medical records. There will be a charge for any additional requests.

authorize the entity listed below to release medical records for the following patients.

PLEASE DO NOT FAX MEDICAL RECORDS

PATIENT INFORMATION

Add Additional Names

Add Additional Records From

Add Additional Records To

INFORMATION REQUESTED

All health care information, including all mental health records.

All Immunization Dates and Growth Charts

Health care information relating to the following treatment, condition, or date of treatment:

Other

For the purpose of

Transfer of Care

For Specialist Visit

Moving or Relocation

I hereby request and authorize the release of requested health care information from the above named party to the corresponding above named party. This authorization will expire 60 days from the date signed. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to Poole and Thomas Pediatrics.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name Signature of Patient or Legal Guardian

Relationship to Patient

Date

Your information will be encrypted.