Request and Authorization for Release of Medical Records

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.
Best Phone Number to reach you:
Please enter a valid phone number.
Please select: We do not email Medical Records

PortalPick up on USB
Name

First NameLast Name
DOB:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name

First NameLast Name
DOB:

MonthDayYear
Date
Name

First NameLast Name
DOB:

MonthDayYear
Date
Charges: There is a fee for obtaining medical records (Pricing subject to change due to size of chart):

No Charge: Last Physical & Immunization Records$20 Electronic CopyIf your chart is retrieved from our offsite storage, there will be an additional $30 fee for obtaining your records.
Is this a permanent transfer?

YesNo
Reason for Requesting Records:

Moving out of areaNot leaving the practice, obtaining Medical Records for personal filesChild has aged out of practiceRequesting records for a specialist or consultation
Leaving practice for another provider (please explain)
Other:
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.
(Parent/Patient/Guardian or Authorized Representative Signature)

Clear
OFFICE USE ONLY

PAIDSCANNED REQUESTPROVIDER REVIEWINACTIVECALLED/LEFT VMDATE COMPLETED_____________BY_______________
Should be Empty: