There is a charge for releasing records to the patient. Ask office staff for applicable charges.
You must supply an unopened commercially packaged device to our office for transfer of records.
Payments: I understand all applicable charges must be paid prior to providing records to someone other than a provider. No charges will be applied for the first copy sent to a specified provider. When requesting records on an electronic storage device, the device must be unopened commercial product.
Restrictions: I understand that the recipient of this information may not use or disclose this information except for the express purpose identified above, unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.
Notice: Unless otherwise specified on this form, this authorization is for full disclosure of all records.
By signing below, I agree to the terms and conditions stated above.
After submitting form, wait for "Thank You" message before exiting page.