Records Release Auth. (Transfer Out)

Northwest Suburban Pediatrics

Please correct the errors described below.

**Transfer Out Form**


*** Complete records are those of NW Suburban Pediatrics physicians only. If you wish to include records from referring and/or previous physicians please be sure to check the consults/specialist records and/or prior physician's records boxes. NW Suburban Pediatrics only guarantees the accuracy and completeness of records generated by a NW Suburban Pediatrics physician. ***

certify the above request is accurate and hereby authorize the release of these records.

*** I agree to pay all fees associated with this release, based on the standard fees outlined below. I understand that all section of this form must be completed before it can be processed. ***

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

As the person signing this authorization, I understand that I am giving my permission to the above-named health care entity for disclosure of confidential health records. I understand that I am giving my permission to release information in my medical record that may include information relating to psychiatric treatment, drug/alcohol treatment, AlDS/HIV testing or treatment of sexually transmitted disease, unless otherwise indicated. I understand that the heath care entity may not condition treatment or payment on my willingness to sign this authorization unless the specific circumstances under which such conditioning is permitted by law are applicable and are set forth in this authorization. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my health records and is not effective as to health records already disclosed under this authorization. A copy of this authorization and a notation concerning the persons or agencies to which disclosure was made shall be included with my original health records. I understand that health information disclosed under this authorization might be re-disclosed by a recipient and may, as a result of such disclosure, no longer be protected to the same extent as such health information was protected by law while solely in the possession of the health care entity.

** I understand that a reasonable fee may be charged with these records. If you are under the age of 18 years old there is $25.00 charge for medical records. Additional $10.00 charge for certified mail **

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