AuthorizationforReleaseofHealthRecordInformation
IherebyauthorizeWashingtonUniversityClinicalAssociates–Cloverleaf Pediatrics,LLCtotransfer,releaseorobtaininformationon:
(Name of Patient)(Date ofBirth)(Last4 digitsof Social Security #)
OBTAINFROM: / DISCLOSETO:WUCA-Cloverleaf Pediatrics, LLC
(Physician/Institution) /
(Physician/Institution/Patient)
Medical Records
(Attention) /
(Address)
4200 N. Cloverleaf Drive
(Address) /
(Address)
Ste. F
(Address) /
(City,State,Zip)
St. Peter’s, MO 63376
(City,State,Zip) /
(Phone)(Fax)
(636) 939-3362 (636) 939-3687
(Phone)(Fax) /
(E-mail address forelectronic deliveryof records)
Forthepurposeof:
ContinuingMedicalCare
Insurance
School
Military
Other(specify) / LegalPurposes
SocialSecurity/Disability
Patient’sRequest
Date(s)ofTreatment: SpecificDates:_thru
Alldates
PleaseCheckSpecificInformationRequestedAllRecords
DischargeSummary
HistoryPhysical
Pathology
MedicationRecords
Other(specify) / LaboratoryReports
X-RayReports
EmergencyRoomReport
NursesNotes
NuclearMedicineReport / ProgressNotes
OperativeReport
OperativeNotes
Endoscopy
RequestsforBillingRecords shouldbesenttoPhysician’s BillingServices (Phone:314-273-0763)
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AuthorizationForReleaseofRecords
Iunderstandthatmyrecordsmaycontainbutarenotlimitedto:history,diagnosis,and/ortreatmentofHIV(AIDsvirus),othersexuallytransmitteddiseases,drugand/oralcoholabuse,mentalillness,psychiatrictreatment,orgeneticcounseling.Igivemyspecificauthorizationfortheserecordstobereleased.
Yes,IconsenttothereleaseofthisinformationNo,Idonotconsenttothereleaseofthisinformation
InitialInitial
- Thisrequestisafreeandvoluntaryactbyme.IunderstandthatImayrevokethisauthorizationatanytimebysendingawrittennoticeofrevocationto: WUCA–Cloverleaf Pediatrics,LLC
4200 N. Cloverleaf Drive
SuiteF
St.Peters,MO63376Office:(636)939-3362
Fax:(636)939-3687
- Therevocationwillnotapplytoinformationalreadyreleasedinresponsetothisauthorization.
- IunderstandthatifIchoosenottogivethispermissionorifIcancelmypermission,Iwill stillbeabletoreceiveanytreatmentorbenefitsthatIamentitledto,aslongasthisinformationisnotneededtodetermineifIameligibleforservicesortopayfortheservicesthatIreceive.
- Iunderstandthatoncemyinformationisusedand/ordisclosedpursuanttothisauthorization,itmaynolongerbeprotectedbyfederalprivacyregulationsandmaybesubjecttore-disclosurebytherecipient(s).
Iunderstandthatareasonablefeemaybechargedunlesscopiesaresenttoanotherphysicianorhealthcarefacility.Thereisa$0.54chargeperpage(pluspostage)forpersonalcopiesofyourrecord.Copiessenttootherrecipients(i.e.attorney,insurancecompanies)aresubjecttofeesasprovidedbystatelaw.
Authorizationisvalideitherfor90daysfromthedateofsignature(ifnototherwisespecified)ORasspecifiedbyselectingoneoftheseoptions:
Thisauthorizationexpiresonthefollowingdate
Thisauthorizationexpiresduetothefollowingeventorspecialcondition
Ihaveread and understand thisconsentand Ihave signed itvoluntarily.
(SignatureofPatientorParent/LegalRepresentative)(Date)
(RelationshiptoPatient—ifnotthepatient)
(Witness)(Date)
(Patient’sAddress,City,State, Zip)(Patient’sPhone)
(Certifiedcopyofappointmentoflegalguardianorpersonalrepresentativeanddeathcertificateofdeceasedpatientmustbeattached)
Revised:5/14
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