Medical Records Request Form

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REQUEST FOR MEDICAL RECORDS

3603 Davis Drive

Suite C-201

Morrisville, NC 27560

Phone (919) 234-1582

Fax (919) 234-1586

www.buildingblockspediatricsnc.com

Patient Name:

Patient Name:

Patient Name:

Patient Name:

Practice Name:

Address:

City:

Telephone number:

Date of Birth

Date of Birth

Date of Birth

Date of Birth

State:

Fax number:

Zip Code:

Address

:

I request/authorize the practice listed below to release/disclose Protected Healthcare Information to

Building Blocks Pediatrics, PLLC.

This request and authorization applies to:

All healthcare information

Other:

Healthcare information related to the following condition, treatment, and/or dates:

Disclosure purpose: ____Coordination of care _____Patient Use ____Legal ___ Other: ____________

The patient or representative may revoke this authorization at any time by notifying the Building Blocks Pediatrics, PLLC

Privacy Officer in writing. This authorization will remain valid indefinitely if no expiration date is specified. Refusal to sign this authorization will not affect your ability to receive treatment or payment of services. Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient that is not protected by federal law.

Yes

No I authorize the release of any Sexually transmitted disease results, HIV/AIDS testing, whether negative or positive, of the person(s) listed above to Building Blocks Pediatrics, PLLC.

Yes

No I authorize the release of any records regarding drug or alcohol abuse, or related to mental health assessments or treatment of the person(s) listed above to Building Blocks Pediatrics.

Please send the requested information to:

Building Blocks Pediatrics, PLLC

3603 Davis Drive, Suite C-201

Morrisville, NC

Phone: (919) 234-1582 Fax: (919)234-1586 [email protected]

Patient/Parent/Legal Guardian Signature:

Printed Name/Relationship to Patient: Date signed:

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