AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION Stepping Stone Pediatrics 15710 NE 24th Street Bellevue WA 9800 Phone: 425-941-9540 FAX: 425-502-6229

AUTHORIZATION RELEASE OF MEDICAL RECORDS PROVIDER TO PROVIDER CONSULT

Stepping Stone Pediatrics 15710 NE 24th St, Suite A Bellevue,WA 98008 PHONE : 425-941-9540 FAX: 425-502-6229
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Please Note: Copy Fee May Be Charged For Medical Records

Above listed patient authorizes the following healthcare facility to make record disclosure:
RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwiserequested. This authorization is valid only for the release of medical information dated prior to and including the dateon this authorization unless other dates are specified.

I understand the information in my health record may include information relating to sexually transmitted disease,acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also includeinformation about behavioral or mental health services, and treatment for alcohol and drug abuse.

This information may be disclosed and used by the following individual or organization:
Please answer only one of the two options:
RELEASE RECORDS TO : STEPPING STONE PEDIATRICS 15710 NE 24th St Suite A Bellevue WA 98008 PH: 425-941-9540

FAX 425-502-6229 FAX ONLY (Evaluations, Summaries, Current Medication list and Laboratory Results and Vaccines )PROVIDER TO PROVIDER CONSULT Please call our office to schedule appointment 425-941-9540 ext 6
Release records from:
FACILITY NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
RELEASE RECORDS FROM : STEPPING STONE PEDIATRICS 15710 NE 24th St Suite A Bellevue WA 98008 PH: 425-941-9540

FAX 425-502-6229 FAX ONLY (Evaluations, Summaries, Current Medication list and Laboratory Results and Vaccines )PROVIDER TO PROVIDER CONSULT Please call our office to schedule appointment 425-941-9540 ext 6
Release records to:
FACILITY NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:*
If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I neednot sign this form in order to assure treatment.

I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for anunauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions aboutdisclosure of my health information, I can contact the authorized individual or organization making disclosure.

I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I amfamiliar with and fully understand the terms and conditions of this authorization.
Signature of Patient / Parent / Guardian or Authorized Representative (Guardian or Authorized Representative must attach documentation of such status.)*

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MonthDayYear
Printed name of Authorized Representative*
Relationship / Capacity to patient*
Address of authorized representative*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
telephone number of authorized representative*

Area CodePhone Number
Email*
example@example.com
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AUTHORIZATION RELEASE OF MEDICAL RECORDS PROVIDER TO PROVIDER CONSULT

Please answer only one of the two options: