Release of Information

Release of Information

For providers to exchange information
Patient ID (if known)
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Please enter the patient's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient (or parent if minor) mobile phone number*
Please enter a valid phone number.
Patient (or parent if minor) email*

Confirmation Emailexample@example.com
Parent/Guardian Name (if patient is a minor)

First NameLast Name
Information to Exchange

Select all that apply
Bay Children's Services has my permission to receive or release information (contained in the Medical Record or otherwise) of the above named patient.*

Entire Medical Record (includes therapy notes)Insurance/BillingTreatment Plan/GoalsTreatment SummaryDischarge SummaryOther
Optional - Service Dates to Include
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Optional - specify particular information to include
Optional - specify information to exclude
Authorized Party Information

With whom we will exchange information
Name of Authorized Party*
Authorized Party's Relationship to Patient*
(pediatrician, therapist, hospital, clinic, etc)
Authorized Party's Phone*
Please enter a valid phone number.
Authorized Party's Fax
Please enter a valid phone number.
Authorized Party's Email

Confirmation Emailexample@example.com
Authorized Party's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Request
Please indicate the reason(s) you would like your health information released:

Treatment/Continuation of CareEducationalBilling or Insurance ClaimsLegal ProceedingsOther
Delivery Method
Method of Release or Exchange of Information:*

Verbal exchange between BCS and the authorized party (via phone, video or in person) as indicated aboveA copy of the medical record information to be released to the authorized party as indicated above
Copy to be sent to authorized individual by the following method of release:

Encrypted EmailCertified MailFax
EXPIRATION OF THIS AUTHORIZATION:
This authorization becomes effective upon signing and will expire one (1) year from the signature date.

REQUIRED ADOLESCENT CONSENT:
All record requests for protected confidential and sensitive services for Adolescent patients aged 12+ require a signed consent from the adolescent.

I hereby authorize Bay Children's Services (BCS) to receive or release any medical information as requested above by signing below.
All record requests for protected confidential and sensitive services for
Adolescent patients aged 12-17 require signed consent from the adolescent.
Signature*

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Release of Information

Information to Exchange

Optional - Service Dates to Include

Authorized Party Information

Reason for Request

Delivery Method