CCP Medical Record Release

Address

Phone Number

I hereby authorize the following healthcare provider to disclose Protected Health Information of the patient(s) listed above

Transfer To Release From

Cherry Creek Pediatrics
4900 E. Kentucky Ave
Denver, CO 80246

Transfer To Release From

Practice/Facility Name

Provider Name

I have a MyChart account for my child(ren)

Yes No

Address

City

State

Zip Code

Phone

Fax

Requested Deliver Method:

Pick-up Secure Email Mail

Purpose for Release: Please Check one of the following

Transfer of Primary Care

Referral to a specialist

Parent/ Attorney/ Insurance/ Other

Reason for the release of records

Records to be released:

Basic medical records: One year of complete medical records: Including immunization records, growth charts, and consults

All medical records

Other: Please specify Below

Expiration: This authorization shall expire upon (check one):

Fulfillment of this request One year from date of signature

I acknowledge that in accordance with the Federal HITECH Act, a flat fee of $6.50 will be charged for an electronic format. Per the Colorado Department of Public Health and Environment, a fee may be charged for paper copies of medical records. The charge is $14.00 for the first ten or few pages, $0.50 for pages 11-40 and $0.33 for pages 41+. Actual postage may also be charged if applicable. There is no charge for physician to physician record transfers.
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV results or AIDS information.
I understand that this authorization may be revoked by me at any time except to the extent that action has been taken in reliance upon it.
The information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected.
I have read the above and authorize the disclosure of the protected health information.

If patient is 18 years of age or older, the form MUST be signed by the patient.

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.

Print Name of Parent /Legal Guardian

Relationship to Patient

Signature of Patient/Parent/Legal Guardian

Date

Your information will be encrypted.