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Section Break
Version: 3
Created: 10/26/2018
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$25 On-Line
IF YOU ARE GETTING THIS FORM IT HAS BEEN PAID FOR THROUGH PAYPAL
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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.
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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
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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.
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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:
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.
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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.
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Information you may release subject to this signed release form is as follows: *
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The purpose/reason for this release of information is as follows: *
If this request is for records to see a specialist that we have recommended please do not complete this form; please call the office.
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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.
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I understand this is a legal representation of my signature.
Clear
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I understand this is a legal representation of my signature.
Clear
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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
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$0
Total
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