Release of Medical Records Out Of Ivy Pediatrics

Release of Medical Records Out of Ivy Pediatrics
Release of Medical Records out of Ivy Pediatrics

If you need to request records for more than one child, please complete this form for each one individually.
220 Bridge Plaza Drive, Manalapan, NJ 07722175 North Broadway, South Amboy, NJ 08879385 Route 18, Suite E, East Brunswick, NJ 088161301 Whitehorse Mercerville Rd, STE 201, Hamilton, NJ 086199 Mule Rd, Unit E16, Toms River, NJ 08755717 N. Beers Street, STE 1F, Holmdel, NJ 077331613 Princeton Ave, Lawrenceville, NJ 08648254 Princeton Hightstown Rd, East Windsor, NJ 08520130 Kinderkamack Rd, Suite 205, River Edge, NJ 07661
Patient Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. I authorize the use or disclosure of the above named individual’s health information, as described below.
2. The following individual or organizations are authorized to make the disclosure: IVY PEDIATRICS, PA.
3. The information may be disclosed to, and used by, the following individuals or organizations:
Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Reason you are requesting records to be released:*
If you are moving within the state, please see a list of our locations above to see if we have an office nearby.

We see patients up to age 25!
4. The information to be disclosed shall be limited to that information necessary to fulfill the above-stated purpose(s) and may include the following items (unless crossed out by me).
Drug and Alcohol abuse information.
Information regarding Human Immunodeficiency Virus (HIV), including laboratory results.
Diagnosis of AIDS or ARC, if applicable.
History and Physical examination.
Consultations.
Genetic testing and counseling, if applicable.
Diagnostic testing, excluding HIV testing.
Discharge summary.
Psychosocial history.
Treatment recommendations.

5. This authorization may be revoked by me at any time except to the extent that IVY PEDIATRICS has already acted in reliance on this authorization. If I revoke this authorization, I need to do so in writing and by email/mail/Fax or hand deliver it.
6. I have a right to inspect the information to be disclosed.
7. I understand that I need not sign this form in order to ensure health care treatment, payment, enrollment in myhealth plan, or eligibility for benefits.
8. Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected by this rule.
9. There is no charge get the records via the portal. Our staff will be happy to set you up with one if you don't have one. Once you have a portal account you can dowload your child records and print them yourself or email them to whomever you wish.

If you want us to print the records for you, the copying fee is $10 for the first 15 pages and 50 cents for each additional page not to exceed $50. Records can be picked up in person or can be mailed (additional postage fee applies).

***PLEASE NOTE FOR SECURITY & PRIVACY REASONS, WE WILL NO LONGER EMAIL RECORDS****
Signature of Parent/Guardian/Patient*
Name of Parent/Guardian/Patient*

First NameLast Name
Your relationship to the patient:*
Date*

MonthDayYear
Date
Should be Empty:

Release of Medical Records Out of Ivy Pediatrics

If you are moving within the state, please see a list of our locations above to see if we have an office nearby.