Pediatric Specialists

Please allow up to fifteen (15) business days for completion.

$30.00 Payment is due at time of request.

Cash

Check #

Credit Card

If you checked Check #, please specify:

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

Name:

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:

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:

I request the release of the following protected information and confidential details of (please check all that apply):

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

*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)

Your information will be encrypted.