Medical Record Release Authorization

PATIENT INFORMATION:

Patient Name *

First

Last

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Patient Date of Birth *

Patient Social Security Number *

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

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Patient Email

Patient Phone

MEDICAL RECORDS RELEASE REQUESTED BY:

Requestor Name *

First

Last

Requestor Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Requestor Email *

Requestor Phone *

RELEASE MEDICAL RECORDS TO:

Please release my medical records to: *

Physician/Clinic's Name or Self

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Phone *

Fax

Address *

Address Line 1

Address Line 2

City

State

Zip Code

OTHER INFORMATION:

Release is for the purpose of: *

If other, write here:

RECORDS TO INCLUDE:

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Date from *

Date to *

Records to include *

If other, write here:

If you have another form you need to attach to this request, you may upload it here.

Click or drag files to this area to upload. You can upload up to 3 files.

Allowed file types include MS Word or PDF.

AUTHORIZATION

Medical Records Release Terms & Conditions *

I accept the terms & conditions

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.

Requestor's Signature *

Today's Date *

New Patients

Current Patients

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

PATIENT INFORMATION:

MEDICAL RECORDS RELEASE REQUESTED BY:

RELEASE MEDICAL RECORDS TO:

OTHER INFORMATION:

RECORDS TO INCLUDE:

AUTHORIZATION

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