Medical Records Release Form

Authorization for Release of Patient Health Information

Patient Name:

Patient Date of Birth:

Address:

City:

State:

Zip:

Phone:

I hereby authorize the protected health information regarding the above named person to be forwarded to:

From:

Person/lnstitution:

Address:

City:

State:

Zip:

Phone:

Fax:

To:

Person/lnstitution:

Address:

City:

State:

Zip:

Phone:

Fax:

I authorize the release of information covering the period(s) of healthcare from:

Date(s):

To date(s):

The type of information to be used or disclosed is as follows:

History and Physical Exam

Consultation reports

Progress notes

Discharge Summary

Operative reports

Copy of doctor's notes

Diagnostic tests (labs, x-rays ... )

Immunization records only

Verbal Only

If checked, please specify:

Other

If checked, please specify:

The following highly confidential items must be checked off to be included in the use or disclosure of other health information:

HIV /AIDS related health information and/or records (the patient 12 or over must authorize this release)

Behavioral or mental health information and/or records (the patient 12 or over must authorize this release)

Information about sexually transmitted disease (the patient 12 or over must authorize this release)

Pregnancy (the patient 12 or over must authorize this release)

Birth control (the patient 12 or over must authorize this release)

Drug/alcohol diagnosis, treatment and/or referral information (the patient 12 or over must authorize this release)

Information about sexual assault/abuse

Information about child abuse and/or neglect

This Information for which I am authorizing disclosure will be used for the following purpose(s):

My personal use (there is a fee for personal copies)

Sharing with other healthcare providers (no charge if sent directly to the other provider - address must be provided as the recipient above)

Other

If checked, please specify:

Authorization for Release of Patient Health Information

This authorization will expire:

Date

(If not otherwise specified, this release will expire within 30 days from the date of the signatures.)

Patient name:

Patient Date of Birth:

Unless revoked, this authorization will expire from the date of signature on the authorization or from the date noted above. For mental health purposes, this authorization will expire one year from the date of signature.

I understand authorizing the use or disclosure of the information identified above is voluntary. I need not sign this form to ensure healthcare treatment; except, however, if my treatment is for the sole purpose of creating health information for disclosure to the recipient identified in the Authorization, in which case Associated Pediatricians, LLC may refuse to treat me if I do not sign this Authorization.

I understand that once Associated Pediatricians, LLC disclosed my health information to the recipient, Associated Pediatricians, LLC cannot guarantee that the recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable Federal and Indiana law governing the use and disclosure of my health information. I understand that I have the right to revoke this authorization at any time.

I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Associated Pediatricians, LLC. I understand the revocation will not apply to information that has already been released in response to this Authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I have read and understand the terms of this Authorization and I have had the opportunity to ask questions about the use and disclosure of my health information. By my signature, I hereby, knowingly and voluntarily authorize Associated Pediatricians, LLC to use or disclose my health information in the manner described above.

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.

Name or Patient of Legal Guardian:

Authorized Signature:

(For information regarding Mental Health, HIV/AIDS, Sexually Transmitted Diseases, Pregnancy or birth Control, the patient 12 years of age or over must sign to release those records)

If signed by legal Guardian, relationship to patient:

Date:

For Mental Health Releases only:

Signature of patient 12 years of age or over:

Witness:

(Mental Health Releases must be witnessed)

(Associated Pediatricians, LLC has checked the identification of the signer and ensures that this is the legal representative who has rights of access.)

Your information will be encrypted.