• Request and Authorization for Release of Medical Records

  • Note:

    1. Please allow 15 days for the records to be processed and released.

    2. Charges associated with copying medical records follows HIPAA HiTech Law (45CRF164.524)

    3. Records request charges and any outstanding balances MUST be paid before releasing full medical records.

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  • I hereby RELEASE and AUTHORIZE Reston Town Center Pediatrics to release medical records of the patient(s) listed (or Self if over the age of 18) including diagnosis, treatment, prognosis and recommendation, as well as other data pertinent to the patient's treatment.** I hereby state that I am the child's parent or legal guardian and have the legal right to make and/or restrict healthcare decisions regarding this child(ren), and that my parental auithority has not been terminated or restricted by the courts. **Reston Town Center Pediatrics only releases medical records to patients, parents of patients or authorized representatives.

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