Authorization to Release or Request Medical Information

Authorization to Release or Request Medical Information

Please complete all fields to prevent delay in the release of information. When transferring records, there is a $10 charge per child or $20 charge per family.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Patient Age
Patient Phone Number

Area CodePhone Number
Patient Email
example@example.com
Parent / Legal Guardian Name

First NameLast Name
Parent / Legal Guardian Phone Number

Area CodePhone Number
Parent / Legal Guardian Email
example@example.com
Provider (who is authorized to release the information)*
Name of Office or Doctor
Provider Address (who is authorized to release the information)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider Fax Number (who is authorized to release the information)*

Area CodePhone Number
Requestor (where you want the information sent)*
Name of Office or Doctor or Individual
Requestor Address (where you want the information to be sent)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requestor Fax Number (where you want the information sent)*

Area CodePhone Number
Information Requested (please check all that apply)*

Abstract (all physician & dictations/test results)Diagnostic Testing & ResultsHistory & PhysicalBilling RecordsComplete RecordsOther
Purpose of Release (please check all that apply)*

Transfer of CareInsurance CoverageCorrespondence/Care Coordination/ReferralMovingLegal PurposesDisabilityPersonal UseOther
Specific Authorization for Release of Information Protected by State or Federal Law: Unless otherwise indicated, my signature authorizes the release of the medical records requested above without exception; including any information concerning HIV/AIDS or AIDS testing, Physiological or Psychiatric Treatment, Alcohol or Drug Abuse, or Genetic Testing.
Exceptions
Signature of Parent, Legal Representative, or Patient (if over 18)*

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This authorization is effective for one year from the date on which it was signed. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to Waggoner Pediatrics of Central Iowa Medical Records Department.
Today's Date*

MonthDayYear
Date
This form does not authorize the redisclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (42 C.F.R., Part 2) and state requirements (Iowa Code CH2288) prohibit further disclosure without specific written consent of the patient, or as otherwise permitted by such state law and/or regulations. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.
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