mpaforkids.com - Release of Records

AUTHORIZATION OF RELEASE OF HEALTH INFORMATION
I, NAME, AUTHORIZE NAME OF PREVIOUS PRACTICE TO RELEASE MEDICAL RECORDS AND INFORMATION TO .
*ATTENTION CORRESPONDING FACILITY*

If releasing records for multiple patients in the same family, please send each patient separately.
I WOULD LIKE THE PRACTICE TO SEND:

ENTIRE MEDICAL RECORDIMMUNIZATION RECORDLAST PHYSICAL EXAM NOTESLAB RESULTS
PATIENT INFORMATION
PATIENT’S NAME

First NameLast Name
DATE OF BIRTH:

MonthDayYear
Date
BEST CONTACT NAME AND PHONE NUMBER:
PREVIOUS DOCTOR’S OFFICE NAME:
PREVIOUS DOCTOR’S ADDRESS:
TELEPHONE:*
Please enter a valid phone number.
FAX:*
HOW WOULD YOU LIKE THE MEDICAL RECORDS TO BE RELEASED?

COPIES BY MAIL (50 CENTS PER PAGE)COPIES BY FAXBURNED TO A CD ($5)
I, NAME , UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION AND THAT THE HEALTH CENTER MAY NOT CONDITION MY TREATMENT BASED ON THIS AUTHORIZATION. I UNDERSTAND THAT MPA WILL CHARGE ME 50 CENTS PER PAGE FOR ANY PRINTED RECORDS AND A FLAT FEE OF $5.00 FOR ANY CD. I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY WRITTEN REQUEST EXCEPT WHEN THE INFORMATION HAS ALREADY BEEN RELEASED BASED ON MY AUTHORIZATION. THIS AUTHORIZATION IS VALID FOR ONE YEAR AFTER THE DATE IT HAS BEEN SIGNED.
Signature of Parent/Responsible Party

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Date

MonthDayYear
Date
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AUTHORIZATION OF RELEASE OF HEALTH INFORMATION