MEDICAL RECORDS RELEASE

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

RELEASE RECORDS FROM:

Name

Attention

Address

City/State/Zip

Phone:

Fax:

Record Inspection or Information Requested

Complete Medical Records

Immunization Records

Referral Summary Notes

Date(s) of Service:

Dates of Sevices:

Other (Specify):

RELEASE RECORDS TO:

Name

Attention

Address

City/State/Zip

Phone:

Fax:

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 30 days.

Legal Proceedings

Subspecialty Referral

Other (Specify)

Patient(s) Name:

Date of Birth

Attached additional Names if Necessary

Patient(s) Name:

Date of Birth

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

Printed Name

Signature

Relationship to Patient

Phone Number

Date Signed

Witness

This authorization expires 90 days from the date signed, or

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!

Office Use Only

Approval:

Date Received:

Date Sent:

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.

Person Sending Records:

Parent/Guardian Signature:

Your information will be encrypted.