MEDICAL RECORDS RELEASE

Partners in Pediatrics

8160 Seaton Place, Montgomery, AL 36116

Telephone: 334-272-1799
Main Fax: 334-272-4876
Medical Records Fax: 334-888-8708

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient(s) Name:

Date of Birth

Please complete one form for each child.

RELEASE RECORDS FROM:

Name of Practice

Attention

Address

City/State

Zip

Phone:

Fax:

Email address

RELEASE RECORDS TO:

Name of Practice

Attention

Address

City/State

Zip

Phone:

Fax:

Email address

Reason for Request

Moving/Transferring to a New Physician for Continued Care.

By moving or transferring records, you will be released as a patient of Partners in Pediatrics after records are sent. Outstanding balances must be paid or will be sent to collections after 90 days.

Military Transfer to New Physician

Please include move date below if requesting an early record release. We will inactivate your chart on this date.

Legal Proceedings

Subspecialty Referral

Other (Specify)

Date

Record Inspection or Information Requested The Authorization is subject to the limitations check below:

Complete Medical Records

Immunization Records

Referral Summary Notes

Progress Notes

Lab Results

Other (Specify):

Dates of Sevices:

Disclosure Requiring Special Consent:

Initial the type of information below to specifically authorize the release of healthcare information relating to the testing, diagnosis, or treatment for:

Initial

Sexually Transmitted Disease

Initial

HIV/AIDS Virus

Initial

Mental Health/Psychiatric Disorders

Initial

Substance Abuse

Record Release Authorization

By signing below, I authorize the use and disclosure of my protected health information as requested. I understand the information may be re-disclosed by the recipient and may no longer be protected by the federal HIPAA privacy rule. I have the right to revoke this authorization except to the extent that Partners in Pediatrics has acted in reliance upon this authorization.

**There will be a charge from Partners in Pediatrics in compliance with federal and/or state law.** **All records will be provided in electronic format unless requested otherwise.**

Indicate Preference:

Please Mail

Will Pick Up

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Printed Name

Patient or Parent/Guardian Signature

Patient signature required if over the age of 19.

Relationship to Patient

Phone Number

Date Signed

Witness

This authorization expires 90 days from the date signed

Please upload a copy of your Driver's License to confirm identity.

Add file

Please upload a file

Medical records received from your previous doctor are reviewed by your Partners in Pediatrics physician. After review your records will be scanned into an electronic health record created for you. If you would like a copy of your records please notify our medical records coordinator, otherwise they will be shredded for your privacy. Thank you!

Your information will be encrypted.