Authorization to Release Health Information

Patient Information
Name of Patient*
Birth Date*

MonthDayYear
Date
Primary Telephone*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Release Health Information From Peak Pediatric Care
Name of Current Healthcare Provider*
Street Address
City*
State*
Zip Code
Telephone
Fax
Release Records To
Please mail or fax the medical records for meWill pick up records in person at Peak or download them from the portal
We are happy to send the medical records to another office on your behalf. Please be sure to include a complete mailing address for the office so that we can make sure they will be mailed to the correct location.
Name of New Healthcare Provider*
Street Address*
City*
State*
Zip Code*
Telephone*
Fax
Name of Parent/Guardian/Patient (if 13+) who will be picking up the records*
Street Address*
City*
State*
Zip Code*
Telephone*
Purpose of Disclosure

Check applicable categories
Transferring from PeakShare with outside provider/specialistRequesting for personal useNeed for legal reason/caseFor schoolOther
Information to Release
Entire Medical Record (except confidential information defined by Massachusetts law)Medical Record for a specific period of time. Please list time period below.Only information from a certain illness or injury. Please describe below.
Please release my medical records fromStart Date* to End Date*
Sensitive Information
By putting my initials by each item below I give permission for Peak Pediatric Care to share this type of information. I understand that if I do not initial the box, Peak Pediatric Care will not share this information about me/the patient's health to the person or organization listed above.
Information about Mental Health Communications

Clear
Information about HIV/AIDS Testing or Treatment

Clear
Information about Venereal Disease (STD)

Clear
Information about Substance (i.e. alcohol or drug) Abuse

Clear
Information about Sexual Assault

Clear
Information about Genetic Testing

Clear
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:
I know I can revoke this form at any time. This means I can tell Peak Pediatric Care to stop sharing my/the patient's information. I know I cannot withdraw information that Peak Pediatric Care had shared before I told Peak Pediatric Care to stop. Peak Pediatric Care may already have shared it. If I no longer want my/the patient's medical record shared I will send a written letter to Peak Pediatric Care telling them

I know I do not have to give permission to share these records. Peak Pediatric Care will not base my/the patient's treatment on whether or not I sign this form.

This approval will end in 12 months or sooner if I send a written letter to Peak Pediatric Care telling them

By signing below I agree that I understand the above and voluntarily allow my/the patient's medical record
Patient's Name*
Parent/Legal Guardian's Name (if applicable)
Relationship to Patient
Signature of Parent / Legal Guardian / Self (if 18+)*

Clear
Date*

MonthDayYear
Date
Patients under the age of 18 may be allowed to provide or decline release without parental consent under Massachusetts law.
Reason for Transferring
MovingChanging InsuranceNeed an office closer to homeTransferring to adult doctorIssue with the officeOther
We are sorry to hear you had an issue with our office. Would you please share additional information so that we can better understand the issue and can take steps to correct this in the future?
Is there any additional information you would like to provide so that we have a clearer understanding of why you are transferring from Peak? We want to be made aware of any issues or concerns our patients have so that we can correct any mistakes going forward.
YesNo
Please provide the best number and time of day to call
Should be Empty:

Patient Information

Release Health Information From Peak Pediatric Care

Release Records To

Purpose of Disclosure

Information to Release

Sensitive Information

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

Reason for Transferring