Each Patient MUST Have a Separate Release Form
Please Print Clearly
Today’s Date: ______
Reason for Request: ______
Patient’s Legal Name: ______DOB : ______/______/______
MM DD YYYY
Patient’s Address: ______
Phone Number: ______q Mother q Father q Self (18+ Years)
q Legal Guardian q Other: ______
I hereby RELEASE and AUTHORIZE ALL Pediatrics to release the medical records of the dependent listed (or self if over the age of 18) including diagnosis, treatment, prognosis and recommendation, as well as other data pertinent to the patient's treatment to the following location listed below. I hereby state that I am the child's parent or legal guardian and have the legal right to make and/or restrict healthcare decisions regarding this child, and that my parental authority has not been terminated or restricted by the courts.
Signature: ______Print Name: ______
FOR RELEASE OF HIV / DRUG / ALCOHOL AND/OR PSYCHIATRIC INFORMATION
AN ADDITIONAL SIGNATURE IS REQUIRED BELOW.
Signature: ______Print Name: ______
REQUEST BEING MADE FOR THE FOLLOWING: $ INDICATES CHARGE FOR RECORD
Consult notes from other specialists will not be included – You must request those through the specialist.
ELECTRONIC MEDICAL RECORDS – 2010-PRESENT
RECOMMENDED - 5-7 BUSINESS DAYS / PAPER CHART – 2009-PRESENT
2 - 6 WEEKS / PAPER CHART – ENTIRE CHART
ONE MONTH OR GREATER
q / EMR - Most Current Physical Note and EMR Medical Summary (FREE – ON CD) / q / LAST PHYSICAL ( $ ) / q / ALL PEDIAFORM NOTES ( $ )
q / Immunization Record (FREE – ON CD) / q / LAST LABS ( $ ) / q / ALL LABS ( $ )
q / EMR – LABS (FREE – ON CD) / q / LAST X-RAYS ( $ ) / q / ALL X-RAYS ( $ )
q / EMR – X-RAYS (FREE – ON CD) / q / ALL OF THE ABOVE ( $ ) / q / ALL OF ABOVE ( $ )
*Medical Record Fee, per state charge schedule, is $25 retrieval and processing fee,
plus $0.50 per page for the first 50 pages and $0.25 for each additional page and the cost of postage.
q MAIL RECORDS TO:
(Postage Fee Will be Assessed) / PICK UP: / q Alexandria q Lorton q Lake Ridge
Please Complete All Information Below To Have Records Mailed
Name: ______
Street Address: ______
City: ______State: ______Zip: ______
Please email or fax completed form to: or 703-499-9670