AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION RECORD REQUEST

This authorization allows the healthcare provider(s) named below to release confidential medical information and records. Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/substance abuse have special rules that require specific authorization.

I hereby authorize Valencia Pediatric Associates to release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by means of mail (sent via certified mail only), fax, or other electronic methods.

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Type of record request:

Immunization Record Only

Complete Medical Record

Reason:

Appt with Specialist

Transferring to new M.D.

Other

If other, specify:

I also consent to the specific release of the following records: (From physician only requests).

Drug/Alcohol/Substance Abuse

HIV Diagnosis/Treatment

Psychiatric/Mental Health

Genetic Information

Tests for Antibodies to HIV

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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.

Signature (Parent/Legal Guardian/Patient)

Relationship

Print (Parent/ Legal Guardian/Patient)

Date:

Would you like to (check one):

Pick-Up

Mail

Fax

Medical Record Copy Fee Mailed (CD Only):
$30.00 for 1st child/ $20.00 for each additional child.

Medical Record Copy Fee Pickup (CD Only) or FAX:
$20.00 for 1st child/ $10.00 for each additional child.

Immunization Record Copy Fee (mail or fax): No Charge

NOTE: Please be advised that record requests may take up to 14 business day.

Records provided by FAX or CD only. Flash Drive/Email is HIPAA Non-Compliant.

Your information will be encrypted.