Request to Release, Copy, or Inspect Protected Health Information
Please correct the errors described below.
For Record Release or Copies:
By signing this authorization, I authorize the party listed below to use and/or disclose certain
protected health information (PHI) about me / my child.
This authorization permits:
to use or disclose to:
Information to be Released/Copied
Information to be Excluded/Not Released
Reason for Record Release or Copy
I understand and agree that I am financially responsible for the following fees associated with my request: copying charges, including, the cost of supplies and labor, and postage related to the production of my information. I understand that the charge for this service is: $.50 per page for the first 25 pages, then $.30 for each page thereafter.