Release of Medical Records

Release of Health Records Request Form

PRP Medical Aesthetics, Dr. Patrick Yam
This form is to authorize the release of medical records and must be signed by the patient or their authorized representative. Any fees associated with review, photocopy, and transfer of records are not included and must be paid prior to release of medical records.
Patient Information

First NameLast Name
PHN (Provincial Health Card Number)
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Email
example@example.com
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records Requested

Other
Records Delivery

Please indicate where the medical records should be delivered
Records delivery method
Address for Records Delivery

Clinic or Doctor's Name (if applicable)

Street Address

CityState / Province

Postal / Zip Code
Fax number for Records Delivery
Please enter a valid phone number.Format: (000) 000-0000.
Person Requesting Records
Patient Authorization (12 years of age or older)

I, the patient, authorize the Hospital(s)/Facility to release the records requested to the person, clinic, address, or fax number specified in the “Records Delivery” section.
Patient Signature (12 years of age or older)
Date Signed

MonthDayYear
Date
Authorization on behalf of patient

By signing below I confirm that I have legal authority to act on behalf of the patient and I hereby authorize the doctor's office to release the records requested to the person, clinic, address, or fax number specified in the “Records Delivery” section.
Authorized Representative

First NameLast Name
Authorized Representative: Reason for records request
Authorization on behalf of an incapable minor. Complete this section if the patient is a minor who is under 12 year old; or under 19 and not actively involved in decisions about health care. Note: Patient authorization is required if patient is involved in decisions about care or has provided consent for care.
Authorization on behalf of an incapable adult

Other
Authorized Representative Signature: By signing below I confirm that I have legal authority to act on behalf of the patient and I hereby authorize the doctor's office to release the records requested to the person named in the “Person Receiving Records” section.
Date

MonthDayYear
Date
Current fees, subject to change, and must be paid prior to records release include:

A00093 Transfer of patient records - basic fee: $43.25

NOTES:
i). This fee is recommended for a simple transfer of records from a physician to
another physician. Photocopying may be charged in addition.
ii). Other direct costs, such as courier services, may be charged in addition based
on the actual cost.
iii). A fee for review of records may be charged in addition if the physician reviews
the records for the purpose of selecting current and necessary medical information to be transferred.
iv). Original records must be retained by the transferring physician as required by
Law
v). When multiple records are being transferred, the total time spent should be taken into account.

A00095 Review of paper or EMR records by physician - per 15 minutes or portion thereof: $122.00

NOTES:
i) The fee for this service can be adjusted at the physician’s discretion based on the time and extent of physician involvement and secretarial and other direct or indirect costs such as cost of supplies to produce an electronic copy .
ii) This fee is for review of the paper or EMR file only.
iii) Photocopying paper records may be charged in addition.
iv) At the physician’s discretion, an additional $1.45 per page for paper copies is billable for large and/or complex charts.

A00096 Photocopying per page (paper copies) (first 10 pages): $2.20
Should be Empty:

Release of Health Records Request Form

Records Delivery