To print: Click here or Select File and then Print from your browser's menu

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
(PHI-Protected Health Information)

Patient Name________________________________________ Date of Birth ____________

Print Name of Parent/Legal Guardian ____________________________________________

Relationship to Patient____________________ Date __________ Expiration Date __________
(expires in 1 year unless otherwise noted)

Please note reason for release_____________________________________________________________

Are you leaving the practice (please circle)? Yes No

I authorize and request release of Medical Records (PHI) from:  

El Camino Pediatrics Medical Group, Inc.
Dr. Frumin, Dr. Nathanson, Dr. Dockweiler, Dr. Gross, Dr. Levy, Dr. Wood,
Dr. Bhasin, Dr. Snyder Block, Dr. Park, Dr. Reinhardt, Dr. Rubin
477 N. El Camino Real, Suite B105
Encinitas , CA 92024
Phone: 760-753-7143

 Please include information regarding the following (circle):

I wish to exclude____________________________________________medical information from being released.

These records will be received or picked up by:

Doctor’s Name or Parent’s Name________________________________________________________________
(person who is to receive records)

Address (if to be mailed*) _________________________________________________

City____________________________________ State___________ Zip_______________

1. You have the right to revoke this authorization in writing unless the Medical Records (PHI) have already been released or if otherwise prohibited by state or federal law.
2. Treatment, payment, enrollment or eligibility for benefits may not be a condition to release Medical Records (PHI). A signed authorization is a requirement in order for Medical Records (PHI) to be released.
3. When this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by above party and may no longer be protected by the federal HIPAA Privacy Rule. El Camino Pediatrics will continue to maintain the confidentiality of our patient’s medical records (PHI) mandated by the federal HIPAA Privacy Rule.

Parent/Legal Guardian Signature_______________________________________________

Date________________________Expiration Date_________________________________
(Expires in 1 year unless otherwise noted)

(*NOTE: There is a $10 fee for chart copy and additional $5 fee if records are to be mailed. Fee is not applicable for records being sent for specialty care at the request of our physicians.)