Inbound - Medical Records Release/Request

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Name of previous doctor/medical office*

Address of previous doctor/medical office

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number of previous office

Fax Number of previous office

Requesting:*

Complete medical recordImmunization record onlyOther

My reason for disclosure:*

Transfer of care to provider at A to Z PediatricsConsultation from a provider at A to Z PediatricsPrecertification /verification of insuranceImmunization record only

Disclosure of confidential information: please check all that apply*

I consent to the disclosure of medical information that may include chemical or alcohol dependence or psychiatric care including ADHD, mood or thought disorders.I consent to the disclosure of medical information that may include blood tests that have been done to detect antibodies to or levels of HIV which is the probable cause of AIDS (acquired immune deficiency syndrome).

This authorization will expire 60 days from today’s date:

Date

By signing this release, I authorize the above named office/medical provider to release protected health information (PHI) as outlined above to A to Z Peditrics LLC (fax 618-344-9246 or mailed to 1230 Tanglewood Parkway, Caseyville, IL 62232 attn: medical records).

When my child's information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that A to Z Pediatrics LLC has acted in reliance upon this authorization (information released prior to revocation). My written revocation may be submitted to: Privacy Officer, A to Z Pediatrics LLC, 1230 Tanglewood Parkway, Caseyville, IL 62232.

I understand that any fees assessed for copying records of the PHI are my responsibility. Fees are determined by Illinois Public Act 92-228. Future further releases of the information requested at this time will be subject to additional fees. The recipient of this PHI will also require the consent of patient, parent or legal guardian for further release. I understand that I/my child will not be denied treatment if I do not sign this authorization for requested use and disclosure of PHI.

Name of Parent or Guardian (or Adult Patient)*

First NameLast Name

Signature*