Medical Release Form

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.

FOR INTERNAL PURPOSES ONLY:

Method of Transfer

Emailed to

Your message will be encrypted.