Medical Records Request & Authorization

Medical Records Request & Authorization
This form is used to request copies of medical records. Only patients or their legal representatives may make a medical record request. Therapy West, Inc. may verify your identity/guardianship. All requests are subject to a reasonable fee. Completion of this form authorizes the use and/or disclosure (release) of individually identifiable health information, as set forth below, consistent with California and federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this authorization.

Please note there is a fee. For electronic delivery, it is $25. If you prefer that the medical records are mailed, the fee is $35.
Parent or Legal Guardian Information:
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Child (Patient) Information:
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address: (if different from address listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient Information:

I authorize Therapy West , Inc. to release health information to:
Full Name/ Business:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Specific Information to be Disclosed
I would like the health information provided in the following format (please select):*

Email (encrypted)FaxMail
Reason I am requesting release of health information (check all that apply):*

InsurancePersonal UseOther
I request medical records fromDate* to Date* .
Type of service requesting reports or notes from (check all that apply):*

Occupational TherapyPhysical TherapySpeech TherapyTWISPP
I am requesting (check all that apply):*

ReportsTreatment NotesOther
I authorize Therapy West, Inc. to release the medical records specified above to the recipient specified above. I understand that I may refuse to sign this Authorization, and my refusal will not affect the child’s ability to obtain treatment. I may inspect or obtain a copy of the health information that is the subject of this Authorization. I have a right to receive a copy of this Authorization. I may revoke this authorization at any time in writing, signed by me on the child’s/patient’s behalf and delivered to Therapy West, Inc., 11460 Washington Blvd, Los Angeles, CA 90066. If I revoke this authorization, the revocation will not have any effect on any actions taken prior to receiving the revocation. I understand that the information disclosed pursuant to this authorization could be re-disclosed by the recipient and may no longer be protected by federal confidentiality law (HIPAA). However, California law prohibits the person receiving this health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law. This Authorization will automatically expire 1 year from the signature date.
Signature*

Clear
Today's Date*

MonthDayYear
Date

My Products*

Electronic/Fax Delivery of Medical Records

$25

Mail Delivery of Medical Records

$35

Total

$0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Medical Records Request & Authorization

Parent or Legal Guardian Information:

Child (Patient) Information:

Recipient Information:

Specific Information to be Disclosed