Request for Records & Release of Information

Today’s Date:*

Date

Patient Name:*

DOB:*

mm/dd/yyyy

Patient's Email*

example@example.com

Patient's Phone Number*

Area CodePhone Number

Which Doctor Did You See? (Can choose more than one)

What would you like to do?*

Medical Records: I hereby authorize the release of all my medical recordsRadiology Xray CD: I also authorize my x-rays to be placed on a disc and sent to me ($15.00 Fee)Authorization: I hereby authorize the listed individual/entity to act on my behalf in all matters related to my medical records, appointment scheduling, and billing related mattersWork note: Please complete a note on my behalf and send using the info specified aboveItemized Billing Receipt, please write which dates of service you need in the "other information below"

Please send my records.... (choose 1)

...TO Michigan Ave Podiatry FROM my previous provider...FROM Michigan Ave Podiatry TO me / a different provider / facility...TO the following individual/entity and authorize them to act on my behalf

Name of person/facility receiving records/receiving authorization:

Name of person/facility to request records from

Do you want your records faxed or mailed?*

FaxedMailed (x-ray CD's will always be mailed)Emailed (will be encrypted and verified email address only)

How would you like your records to be sent? You can select multiple methods.

FaxedMailed (X-Ray CDs will always be mailed)- $6.50 Mail ChargeEmailedOther

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Fax Number to send records

Area CodePhone Number

Email to send records to

example@example.com

What information do you need included in your work/school note?

Please upload any forms that need to be completed (i.e. FMLA, etc)

Browse Files

Other information:

Terms:

I, the undersigned, hereby request the release of my medical records from Michigan Avenue Podiatry LLC 1, Elmhurst Podiatry Center, LTD. Olympia Fields Foot & Ankle (All Parties) I understand and agree to the following terms and conditions:

Authorization: I authorize Michigan Avenue Podiatry LLC 1 and All Parties to release my complete medical records, including but not limited to, medical history, diagnostic tests, treatment records, medication history, and any other relevant health information to the designated recipient(s) specified below.

Purpose of Release: I understand that my medical records will be released for the purpose(s) specified above and that I should ensure the recipient(s) adhere to all applicable laws and regulations governing the use and confidentiality of medical records.

Expiration Date: If no expiration date is specified, this authorization will remain in effect until revoked by me in writing.

Revocation of Authorization: I retain the right to revoke this authorization at any time, in writing, except to the extent that action has already been taken in reliance on this authorization. I understand that revocation will not apply to information that has already been released in accordance with this authorization.

Fees: I understand that there may be reasonable fees associated with copying and releasing my medical records, as permitted by state and federal law. I agree to be responsible for any applicable fees.

Confidentiality: I acknowledge that my medical records may contain sensitive and private information. While Michigan Avenue Podiatry LLC 1 and All Parties will take reasonable measures to maintain the confidentiality of my records, I understand that the recipient(s) may have their own privacy policies and procedures which can be requested from Michigan Avenue Podiatry LLC 1 and All Parties in writing to admin@michiganavenuepodiatry.com

By signing above, I acknowledge that I have read, understood, and agree to the terms and conditions outlined in this disclaimer for the release of my medical records.

I understand that record requests take up to 7-10 business days to process from submission of this form

Patient’s Signature:*

Name*

First NameLast Name

(Parent if patient is a minor)

My Products

Radiology CD$15.00

A CD with all your radiology (X-ray) images

Quantity

Mailed Records$6.50

All your medical records mailed to your home or address confirmed in this form

Quantity

Handling Charge$33.60

Handling Charge per Code of Civil Procedure 735 ILCS 5/8-2001(d) and (h) in the State of Illinois

Quantity

Enter coupon

Total $0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.