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. Include (Indicate by checking below): Please note that the information will not be released if not checked.

Delivery Method
Please consider the environment. When possible, we will provide the information you requested electronically please check preference:
Patients with an active electronic medical records account (patient portal) can request electronic delivery via secure web patient portal at no cost. Please confirm by checking the box below: I have an active patient portal account and understand the medical record(s) I requested will be sent to my patient portal account at:
You must have an active patient portal account for this delivery method. If you select this delivery method and your medical records cannot be delivered to your account, they will be mailed to above stated address on an encrypted portable media (e.g. CD/DVD, Flash Drive [with restrictions], etc.)
The purpose(s) for which disclosure is authorized (check where applicable):