RTC Pediatrics Request and Authorization for Release of Medical Records

RTC Pediatrics Request and Authorization for Release of Medical Records
RESTON TOWN CENTER PEDIATRICS a division of Trusted Doctors LLC
1830 Town Center Drive, Suite 205 Reston, VA 20190
P: 703-435-3636 / F: 703-435-9145
Patient(s) Information
Best Phone Number to reach you:
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Email
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(Incoming) I authorize the release of medical records To RTC Pediatrics From: Practice name . Fax# Please confirm with practice
***Incoming Records (transfer to our Practice)
*PLEASE DO NOT FAX MORE THAN 50 PAGES. THANK YOU*
(Outgoing) I authorize the release of medical records From RTC Pediatrics To:
Practice name . Fax# Please confirm with practice
***Outgoing Records (transfer to another Practice)
**For Outgoing records**

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

2. We do not email Medical Records.

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

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

Street Address

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Postal / Zip Code
Is this a permanent transfer?
Reason for Requesting Records:
Please explain
Please explain
I hereby AUTHORIZE RTC Pediatrics to RELEASE/REQUEST 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. **RTC Pediatrics only releases medical records to patients, parents of patients or authorized representatives.
(Parent/Patient/Guardian or Authorized Representative Signature)
Date:

MonthDayYear
Date
Form Disclosure

By submitting this form, you agree that [Practice Name] may use the information you provide to respond to your request and, where applicable, to contact you about your child's care. We do not sell your information. View our full Privacy Policy at https://www.rtcpeds.com/privacy-policy.
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