Medical Records Release Authorization (From HIP)

Please correct the errors described below.

HIP will complete all medical records requests within 5-10 business days. If we find a request is requiring more time, we will call the parent/guardian named below and notify them of the delay. The chart basics, including immunization records, growth and development charts, last well visit notes, and problem list are copied at no charge. If you are requesting a copy of the full chart, there may be a charge assessed. The charges consist of $0.05 per sheet copied, actual postage and $0.20 per envelope, which is lower than the Colorado State statute § 6 C.C.R. 1011-1, Chapter 2, Part and in compliance with HIPAA § 165.524 (c,4). Payment is required before records will be mailed or picked up. Thank you.

I authorize Highlands Integrative Pediatrics to release protected health information to:

Please send:

Add Child

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.

(If over 18 years of age, patient must sign)

** PLEASE NOTE: This authorization will expire 90 days after the date identified above. In the event that you need to cancel this authorization, the cancelation must be received in writing. If the records have already been sent to the organization listed on this request, a separate written revocation must be sent to those persons.

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