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:*

Please enter a valid phone number.

Email*

example@example.com

(Incoming) I authorize the release of medical records To RTC Pediatrics From: Practice name . Fax# Please confirm with practice
(Outgoing) I authorize the release of medical records From RTC Pediatrics To: Practice name . Fax# Please confirm with practice

***Incoming Records (transfer to our Practice)

Immunization Record ASAP - Patient in office - Thank you. PLEASE FAX TO 703-435-9145Growth ChartsProvider Notes from each patient's Last Well VisitIf patient has seen specialists, have more complicated medical history, or are on any medication(s).

*PLEASE DO NOT FAX MORE THAN 50 PAGES. THANK YOU*

***Outgoing Records (transfer to another Practice)

Fax Last Well Visit Notes, Immunization Records, Growth chart -FREE-All records release to the PORTAL $20All records in USB to be picked up in office $25If your chart is retrieved from our offsite storage, there will be an additional $30 fee for obtaining your records.

**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.*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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 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:

Date