Name of Patient)(Date Ofbirth)(Last4 Digitsof Social Security #

Name of Patient)(Date Ofbirth)(Last4 Digitsof Social Security #

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

PleaseCheckSpecificInformationRequested
AllRecords
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,IconsenttothereleaseofthisinformationNo,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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