Pediatric Specialists

Medical records will be sent USPS Certified Mail (signature required) to:

Send Records To:

Address:

City:

State:

Zip+4:

Patient Name:

DOB:

Age:

Best Contact Number:

I, (Name)

authorize Pediatric Specialists of Foxboro and Wrentham to release my (my child's) entire medical record.

For the following purpose(s):

Leaving Practice

Legal Matter

Medical Care

Insurance Reasons

Personal Reasons

Specialist(s)

Other

If you selected Other, please specify:

I request the release of the following protected information and confidential details of (please check all that apply): It is mandatory that this section is completed if any of the below information is to be included.

Alcohol and Drug abuse records protected by the Federal Confidentiality Rules [42 CFR Part II]

Professional Service(s) of a license Psychologist

Social work counseling/therapy

HIV Test Results

Domestic violence counseling

Psychotherapy notes

Sexual Assault Counseling

Information to be released (please check all that apply):

Entire Medical Record

Lab & X-Ray report(s) only

Specialist(s) Notes (include specialists' name)

Other

If you selected Specialist(s) Notes, please specify:

If you selected Other, please specify:

*Release of Protected Health Information from outside of Pediatric Specialists: Request of records means records created from a period of time while the person(s) listed above have been patients at Pediatric Specialists of Foxboro and Wrentham. If records from an outside agency (laboratory, specialists, etc.) are included, Pediatric Specialists cannot attest to the completeness or accuracy of those records.

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 of Parent (if under 18) or Patient (if 18 or above):

Relationship to patient:

Today's Date:

(Request only valid for 6 months from today)

Please allow 30 days for your request to be processed. Please call our business office between the hours of 9 am -12 pm and 1pm -5 pm at (508) 543-8140 to finalize and pay for records.
THIS REQUEST WILL NOT BEGIN PROCESSING UNTIL PAYMENT IS RECEIVED.

I understand that any medical visits that occurred outside of PSFW will not be included in this request unless the patient had these records transferred to us previously. Outside records are not automatically sent to our office without express patient permission filed with the specialist office directly.

Your information will be encrypted.