Medical Release Form

Date

Patient

Date of Birth:

Address

City

State

Zip

Phone

Because records may contain sensitive information, we may ask you to sign and return the enclosed Authorization for Release of Medical information.

There is a fee of $20.00 for each medical record transferred. The fee is expected prior to release of records. Checks should be payable to: Pediatricians, Inc.

If you insist on records on off-site storage, there is an additional charge of $20.00 to cover the cost of retrieving the record.

Please Note: Medical records cannot be copied upon demand. The Normal completion time is 5-7 business days. Your record will be placed in long-term storage for 7-10 years.

After that time, it may not be available. We suggest you make a copy of any pertinent information, I.e Immunizations, for your personal records.

If you have any questions about this form or the request, please call at (781) 729-4262

Reason for Request-(transfer of care, specialist appt, etc.)

Any specific information to be released & dates of care included

If Mailing

Name

Address

City

State

Zip

If patient is 18 years old and the medical record is going to be picked up by someone else the patient must sign below to release their records.

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.

Patient's Signature

Please list names of people who you allow to pick up your records

Please have my physician send the following information: (mark all that apply)

Complete record

Progress Notes

Labs

Specific dates of treatment

X-Rays

Well Visit

Shot Record

Specific dates of treatment

Other

This authorization is valid for 90 days and may be revoked at any time in writing prior to the expiration date.

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.

Patients Signature

Parent / Guardian SIgnature

I understand that my medical record contains information in reference to drug and or Alcohol abuse, Psychiatric, Venereal disease, Social service, Hep B testing/Treatment, and/or sensitive information, I agree to its release.

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.

Patient Signature

Parent / Guardian Signature

Date

In addition to the above signatures, if you want your HIV (AIDS) testing/treatment records released you must sign and date the line below.

I agree to the release of this information.

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.

Patient's Signature

Parent/Guardian Signature

Your information will be encrypted.