Release of Medical Records from Acton

Patient Name (Last, First, Middle)

Date of Birth

Phone Number

Address

This authorization applies to all information. I understand that the information may contain psychiatric/psychological, alcohol/drug abuse, AIDS/HIV information and/or other sensitive health information for all treatment dates and I expressly consent to the release of all information.

I hereby authorize Action Road Pediatrics, LLC to release my medical records:

TO:

ADDRESS:

PHONE:

FAX:

PURPOSE OF YOUR REQUEST:

LEAVING ACTION ROAD PEDIATRICS (IF YES, WHY?)

WOULD YOU LIKE TO SPEAK WITH THE MANAGER OF ARP?

YES NO

MOVING:

TRANSITION TO ADULT CARE:

PERSONAL:

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.

Parent/Legal Guardian

Date

Parent/Legal Guardian SIGNATURE

Patient Signature if 14 or older

Date

Witness Signature

Date

I understand the information released will be limited to information necessary to fulfill the need or purpose for the disclosure. If I have authorized the disclosure of information to a recipient who is not subject to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), then the recipient may re-disclose it and it may no longer be protected under HIPAA, a federal privacy law. This authorization is valid for ninety (90) days from the date of signature, unless otherwise noted. This authorization only applies to treatment occurring before the date of signature. I understand I may see and copy the information described on this form if I ask for it, and I may receive a copy of this form after I sign it. Before requesting medical record copies, please ask about the copy fee by law that may apply. I represent that I have authority to and voluntarily grant permission for the information to be released and described above.

Your information will be encrypted.