Medical Records Release Form

Fees for Copies of Health Information

In order to better serve you, our facility contracts with HealthPort to process your request for copies of medical records.

There will be a minimum fee of $10 charged for reproduction of records unless you are referred by our facility to another provider.

Effective January 1, 2008, fees per page will be the following:

$.75 per page for 1-25 pages

$.50 per page for 26-100 pages

$.25 per page for 100+pages

Plus actual postage

All invoices will be billed by HealthPort. Upon receipt of your invoice, simply include the bottom portion of your invoice along with your check for the balance due. Your invoice will include a phone number if you choose to pay by credit card or you may go to www.HealthPortPay.com to pay your invoice. If you have any further questions, feel free to contact HealthPort customer services at 1-800-367-1500.

REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION

Patient name

Date of Birth

Patient’s telephone

I hereby request (Insert name of sending facility or provider)

to provide me or the person listed below with access to protected health information about my child that is maintained by (Inser Name of receiving person, facility, or provider)

Specifically, I would like to:

Purpose of releasing this information: (i.e., relocation, transfer care, legal reasons, etc.)

I would like the following records:

Copies of all medical records for the dates of treatment (please write “all” if you want information for all dates of treatment):

From

Other (please specify):

Sender’s Information:

Recipient’s Information:

Name of Facility or provider who will be sending records

Name of Facility or provider who will be receiving records

Address

Phone

Fax

I understand that I may be charged a fee for the preparation of a summary or explanation of my child’s protected health information. I also may be charged a fee for reproduction costs to obtain a copy of my child’s protected health information or to obtain a copy of the summary or explanation. If I ask to have the information mailed to me, I understand that I may be charged a fee for mailing costs. If I ask for an electronic copy of my child’s protected health information, I understand that I may be charged a fee for the media (CD, flash drive) on which my copy is stored and provided to me and for the labor costs associated with making the copy.

If I ask to have information e-mailed to me or another person, I understand that sending e-mails is not always secure, and I agree that I will not hold

responsible if the information e-mailed is intercepted by an unauthorized third party.

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.

Signature of Patient or Representative

Date

Print Name

Relationship of Representative to Patient (please describe Representative’s authority to act on behalf of the Patient):

Your information will be encrypted.