Authorization for Request of Medical Records and Disclosure of Protected Health Information to Third Parties

Patient Information

Beyond Limits Pediatric Therapy Center 4900 Ivey Road, Suite 1720 Acworth, GA 30101 PHONE: 770-917-5737 FAX: 770-917-5740 EMAIL: info@beyondlimitstherapy.org WEB SITE: www.beyondlimitstherapy.org

PATIENT NAME

DOB

Please enter a date that isn't in the future.

Address

A) Release Medical Records

I authorize BLPTC to RELEASE my child’s medical records to:

Name

Address

State & Zip

Phone

Please enter a 10-digit phone number.

Fax

Please enter a 10-digit phone number.

B) Obtain Medical Records

I authorize BLPTC to OBTAIN my child’s medical records from:

Name

Address

State & Zip

Phone

Please enter a 10-digit phone number.

Fax

Please enter a 10-digit phone number.

Information That May Be Released

Please check information that may be released. (Please note that only records that have been ordered by our office will be released.)

All records (will include Audio, ST and OT Evaluations, Plans of Care and Office Notes)

Evaluations

Plans of Care

Office Notes

Records Delivery

These records are to be:

Picked up

Mailed to

Faxed to

Emailed to

Authorization and Signature

I hereby authorize this practice to release my medical records, including, but not limited to all of the above. By signing this consent, I completely release the entity, facility, or medical practitioner from any and all liability which may result or could result from the release of such information. I also understand this authorization is only valid for 12 months. However, I reserve the right to revoke this authorization at any time.

SIGNED

DATE

Printed Name

Street Address

relationship to patient

City, State, Zip Code

contact number

Please enter a 10-digit phone number.

Witness

WITNESS

DATE

Printed Name

Beyond Limits Pediatric Therapy Center/Beyond Limits Audiology