Patient Records Request

Record Request and Release of Information Form

Record Release Form

Client/ Patient Information 

Client Name
Client Name
First
Last
Client Address
Client Address
City
State/Province
Zip/Postal

Information of person or entity receiving records

Receiving Entity's / Individual's Address
Receiving Entity's / Individual's Address
City
State/Province
Zip/Postal
Protected Health Information to be Released
Purpose of this Authorization for Release: (check all that apply)
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.

*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

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