Medical Records Release

REQUEST FOR RELEASE OF MEDICAL RECORDSHeading
The purpose of this form is to obtain authorization for the use or release of protected health care information. Patients have the right to receive one free copy of their medical records. There will be a charge for any additional requests.
I, authorize the entity listed below to release medical records for the following patients.
PLEASE DO NOT FAX MEDICAL RECORDS
Patient Information:
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I am requesting records to:*

Transfer TO Poole and Thomas PediatricsTransfer FROM Poole and Thomas Pediatrics
Records To:
Records To: Doctor or Group Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Records From:
Records From: Doctor or Group Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Information Request:
All health care information, including all mental health records.All Immunization Dates and Growth Charts
Other:
Health care information relating to the following treatment, condition, or date of treatment:
Please list specified records needed
For the purpose of:

Transfer of CareFor Specialist VisitMoving or Relocation
I hereby request and authorize the release of requested health care information from the above named party to the corresponding above named party. This authorization will expire 60 days from the date signed. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to Poole and Thomas Pediatrics.
Signature

Clear
You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Date

MonthDayYear
Date
Printed Name of Patient or Guardian
Relation to Patient
Should be Empty:

REQUEST FOR RELEASE OF MEDICAL RECORDSHeading

PLEASE DO NOT FAX MEDICAL RECORDS

Patient Information:

Records To:

Records From:

Information Request: