Patient Records Request

Client/ Patient Information

Client Name

First

Last

Client Address

City

State/Province

Zip/Postal

Client Date of Birth

Client Phone Number

Client Social Security Number

Information of person or entity receiving records

Receiving Entity/ Individual’s Name

Receiving Entity's / Individual's Address

City

State/Province

Zip/Postal

Receiving Entity's / Individual's Fax Number

Receiving Entity's / Individual's Phone Number

Receiving Entity's / Individual's Email

Protected Health Information to be Released

Dates of Services to be Released if you only want partial record sent:

Purpose of this Authorization for Release: (check all that apply)

Coordinate treatment and continuing care

Compliance Reporting/Monitoring

Exchange of information for assessment/diagnosis

Treatment Planning

Employment

Legal

OtherOther

Information May Be Shared Via:

I agree that this information may be sent in the following authorized manner: (check each that apply)

I have had the full opportunity to read and consider the contents of this authorization. I understand that by signing this form, I am confirming my authorization for the use and or disclosure of my protected health information, as described in this form.

Date of Client Signature

Client Signature

Clear

Date of Personal Representative Signature

Signature of Personal Representative

Clear

Relationship of Representative to Client

*Please note that medical records are retained for 10 years, and therapy/counseling records retained for 8 years.

**Records requested by other like providers will be exempt from fees. Records requested for all other purposes will be charged the following fees: - Clerical Fee $28.00 - First 30 Pages $0.20Per Page - After 30 Pages $0.10

Record Request and Release of Information Form