-Medical Records Release Form - From WCP ON-LINE

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Version: 3
Created: 10/26/2018
$25 On-Line

IF YOU ARE GETTING THIS FORM IT HAS BEEN PAID FOR THROUGH PAYPAL
Our offices charge a $25.00 per person fee to release records.

Requests are processed in the order in which they are received, but all requests will be processed within 30 days in accordance with HIPAA requirements.
Once you submit your form it will take you to PayPal

Once you have completed the PayPal $25 transaction, your request will be sent to our office.

If you have question or problems, please call the office at 630-385-2360
By signing this form, I authorize Whole Child Pediatrics to release my or my child's confidential health information. A copy of the medical record (s), or a summary or narrative of my protected health information may be released to the physician/person/facility/entity listed below.
Patient Name Patient Name * First Last
Patient DOB Patient DOB * / MM / DD YYYY
Email *
I understand that I must check one or more of the following types of health information that I
do not want released. I understand that if I do not check any of the three following items, the health information released may include the following:

I understand that I must check one or more of the following types of health information that I
do not want released. I understand that if I do not check any of the three following items, the health information released may include the following: Diagnosis, evaluation and/or treatment for alcohol and/or drug abuse Records of HTL V-III or HIV testing (AIDS test) result, diagnosis and/or treatment Psychiatric, psychological records or evaluation and/or treatment for mental, physical and/or emotional illness including narrative summary, test, social work assessment, medication, psychiatric examination, progress notes, consultations, treatment plans and/or evaluation.

For patients 12 years and older, protected health records concerning sexually transmitted diseases (STD's including HIV/AIDS), pregnancy, sexual behavior, drug or alcohol abuse, or mental health issues, the patient must give consent for release concerning these issues and sign this form below.
Release my protected health information to the following
Physician/person/facility/entity/and/or those directly associated in my medical care:

By law, Whole Child Pediatrics can only allow access to protected health information performed by the staff/providers at Whole Child Pediatrics. Other health information (e.g., specialist reports, old medical records prior to Whole Child Pediatrics) must be obtained from the primary source.
Information you may release subject to this signed release form is as follows: *

Information you may release subject to this signed release form is as follows: Complete Records History & Physicals Progress Notes Plan of Care Lab Reports Radiology Reports Pathology Reports Treatment Record Operative Reports Hospital Reports Medication Record Vaccine Records Other (please specify) Other (please specify)
Name Name * First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
The purpose/reason for this release of information is as follows: *

The purpose/reason for this release of information is as follows: TRANSFERRING ALL CARE FROM WHOLE CHILD PEDIATRICS TO ANOTHER FACILITY/PROVIDER Other Other

If this request is for records to see a specialist that we have recommended please do not complete this form; please call the office.
I understand I have the right to revoke/withdrawal this authorization at any time as long as it is in writing to the medical record contact person at this site except to the extent the action has already been taken to release the information. Authorization is valid unless revoked but will expire in one year after signing.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Our offices charge a $25.00 per person fee to release records.

Requests are processed in the order in which they are received, but all requests will be processed within 30 days in accordance with HIPAA requirements.
Once you submit your form it will take you to PayPal

Once you have completed the PayPal $25 transaction, your request will be sent to our office.

If you have question or problems, please call the office at 630-385-2360
$0

Total

-Medical Records Release Form - From WCP ON-LINE

Section Break

$25 On-Line

Our offices charge a $25.00 per person fee to release records.

Once you submit your form it will take you to PayPal

By signing this form, I authorize Whole Child Pediatrics to release my or my child's confidential health information. A copy of the medical record (s), or a summary or narrative of my protected health information may be released to the physician/person/facility/entity listed below.

Release my protected health information to the following Physician/person/facility/entity/and/or those directly associated in my medical care:

Our offices charge a $25.00 per person fee to release records.

Once you submit your form it will take you to PayPal

$0

Total

Release my protected health information to the following
Physician/person/facility/entity/and/or those directly associated in my medical care:

$`0`