Record Release/Transfer

DATE:

Add patient information

I AUTHORIZE:

NAME/PHYSICAN/FACILITY/AGENCY:

STREET ADDRESS:

CITY:

STATE:

ZIP:

NEW ADDRESS: (where we can reach you)

STREET ADDRESS:

CITY:

STATE:

ZIP:

PHONE NUMBER:

TO RELEASE MY MEDICAL RECORD TO: ( IF RECORDS ARE BEING TRANSFERRED TO A DIFFERENT DOCTOR’S OFFICE MEDICAL RECORDS MUST BE PICKED UP FROM OFFICE BY PARENT)

NAME/PHYSICAN/FACILITY/AGENCY:

STREET ADDRESS:

CITY:

STATE:

ZIP:

PHONE NUMBER:

FAX NUMBER:

REASON FOR REQUEST/DISCLOSURE:

Entire Medical Record ($21.00)

Vaccine Record ONLY

Vaccine Record, Growth Charts, and Last PE ($10.00)

I understand that there is a copy fee of $21.00 per chart and the chart will be ready for pick up in approximately 2- 3 weeks after we have received payment. If only a release of the vaccine record is needed there is no charge. Once medical records are copied and released the medical record will be placed in storage and not easily accessible.

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.

PARENT/GUARDIAN NAME:

Your information will be encrypted.