Medical Record Release Authorization

Please complete this form to request a copy of your medical records.

Upon submission of this form our office will receive your request by email for processing. You will also receive a copy of your request for your records.

Please note: The information you provide will not be retained on our website or web servers.


Please provide only the last four numbers of the patient's social security number.



Physician/Clinic's Name or Self



Click or drag files to this area to upload. You can upload up to 3 files.
Allowed file types include MS Word or PDF.


I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure, and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I understand that the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Medical Records Department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

Fee Information: Community Choice Pediatrics contracts with ScanStat Technologies to copy and provide all medical records requested from our office. ScanStat Technologies reserves the right to charge the medical record state fee structure as set forth in the state statute. Copy charges plus postage will be invoiced to you from ScanStat Technologies, LLC with all of the necessary directions to receive your records. By signing this authorization, you are agreeing to pay ScanStat Technologies for your records. In the case of continuity of care or personal copy to patient, ScanStat Technologies may transfer a minimal portion of your records as a courtesy. Once your request has been submitted feel free to call ScanStat Technologies at 866-442-9026 for any questions on the
status of your request.

I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand
the terms and conditions of this authorization.
Clear Signature

Our core values


We place ourselves in the shoes of our patients and parents as we mindfully listen, observe, and examine judgment-free.


By continually sharing information and seeking the advice and opinions of each other, our patients receive the benefit of the combined knowledge, skill, and experience of all the healthcare professionals who work in the practice.


A safe and healthy child makes a community stronger, and a strong community produces safe and healthy children.