MEDICAL RECORD RELEASE AUTHORIZATION)(FROM us)

There is a fee of $15 for charts less than 50 pages, and $25 for charts bigger than 50 pages for the cost of supplies for and labor of copying, as well as storage for the requested information. Postage will be charged on an individual basis. An additional fee of $15 will be added for rush requests inside the allowed 15 day processing. Outstanding bills are due immediately with a forwarding address. Non-reconciled accounts are subject to collections 30-days following records transfer. Use of services and facilities after 30-day grace period are considered unauthorized and patients will be billed per usage. Records requests are handled pursuant to federal and state regulations, including Virginia code 32.1-127.1:03

Please call office to pay above fees

Immunization and growth curve records only (No charge)

Date:

I authorize the release of:

my own

my child(ren)’s

medical records from (date):

to (date):

All Records

Please forward all records to the following address: (Please print clearly)

To (Practice/Doctor’s Name):

Address:

Review Appointment if records will be hand transported

please make decline appt

Reason for records transfer:

Current billing address:

Telephone:

Alternate Telephone:

Add another

I understand that I am responsible for providing correct and legible information. Should I choose not to have these records sent directly to another doctor’s office, I understand that per Union Mill Pediatrics’ Policy, I must make or decline an appointment to review them in the office prior to taking them, and further agree accept complete responsibility for the safe keeping of the records I take.

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

Signature:

Individual 18+, Parent or Legal Guardian

Date:

Your information will be encrypted.