Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information
Your Information
Supporting Documentation
Authorization to release my medical records
A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purposes of continuing to receive medical care does not pay a fee for medical record copies. Request for medical record copies for any use other than medical care may be subject to a fee. If a fee does apply, you will be notified prior to your request being processed. The HIPAA Privacy Rule permits healthcare providers to impose a reasonable, cost-based fee to an individual requesting a copy of medical records. The fee may only include the cost of labor, supplies and postage.
Information to Release
Disclosure of sensitive information
You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing. To exclude this information from disclosure, check the apropriate checkbox(es). To EXCLUDE this information with disclosure, check the last checkbox in the list.

Delivery Method