Records Request Form

1. Patient Details

FULL NAME

SSN / HEALTH RECORD #

BIRTHDATE

MAILING ADDRESS

CITY

STATE

ZIP

2. Current Provider Details

Please enter the information for the party responsible for releasing the records to Children's Medical Group.

NAME

PHONE

FAX

ADDRESS

CITY

STATE

ZIP

3. Records to Release

Do you want to release your entire record?

Please add any additional details below:

THE IDENTIFIED INFORMATION WILL BE USED FOR THE FOLLOWING PURPOSE:

4. Records Recipient

THE IDENTIFIED INFORMATION MAY BE USED BY OR RELEASED TO THE FOLLOWING INDIVIDUAL(S) OR ORGANIZATION(S): (check one)

Children’s Medical Group, P.A. (AIRPORT LOCATION) Children’s Medical Group, P.A. (PROVIDENCE LOCATION)

5. Expiration

THIS AUTHORIZATION WILL EXPIRE ON:

If an expiration date is not specified, this authorization will expire twelve (12) months from the date on which it was signed.

6. Agreement & Signature

Please read the information below before proceeding:

I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand once the information below is released, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the practice. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure health care treatment.

By signing your name below, you are signing the document electronically. You agree that your electronic signature has the same legal validity and effect as your handwritten signature on the document, and that it has the same meaning as your handwritten signature.

PARENT/LEGAL GUARDIAN SIGNATURE

PARENT/LEGAL GUARDIAN NAME (typed)

RELATIONSHIP TO PATIENT

DATE

AGREEMENT ACCEPTANCE

My signature above acknowledges that I have read, agree and consent to the above health record policies of Children's Medical Group. I authorize the transfer of my child's medical records to be transferred as described on this form.

WITNESS SIGNATURE

WITNESS NAME (typed)

DATE

(Airport Office)

To have your child’s medical records from a previous provider sent TO Children’s Medical Group, complete form below. Alternatively, you may download the form below and bring it to our office.

1. Patient Details

2. Current Provider Details

3. Records to Release

4. Records Recipient

5. Expiration

If an expiration date is not specified, this authorization will expire twelve (12) months from the date on which it was signed.

6. Agreement & Signature

Please read the information below before proceeding:

By signing your name below, you are signing the document electronically. You agree that your electronic signature has the same legal validity and effect as your handwritten signature on the document, and that it has the same meaning as your handwritten signature.

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