• Patient authorization for copy and release of records from Henry Fertility.

     

    I,

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  • Hereby authorize Henry Fertility to copy and release my health information to:

  • Please state what portion of your health information record you would like copied and released; for example,

  • If B.) "Partial medical record" was selected above, please state pregnancy-related information from to .

  • Copying Fees: Henry Fertility will forward your records to a physician one time at no charge. All additional requests will incur a $20 copy fee. Henry Fertility will charge a $20 copying fee to all requests made by a patient to obtain records for their personal use.

    Please note we may only release records for services provided with Henry Fertility. Records will be sent out within 30 days of receipt of this request. If you have not been seen within the past 5 years and your chart is in storage, records will be sent out within 60 days. This consent expires 60 days from the date signed.

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