RTC Pediatrics Request and Authorization for Release of Medical Records Logo
  • 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

  • (Incoming) I authorize the release of medical records To RTC Pediatrics From: .   Fax#      
    (Outgoing) I authorize the release of medical records From RTC Pediatrics To: . Fax#      

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

  • **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.*

     

  • 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.

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