REQUEST FOR MEDICAL RECORDS
3603 Davis Drive
Suite C-201
Morrisville, NC 27560
Phone (919) 234-1582
Fax (919) 234-1586
www.buildingblockspediatricsnc.com
Patient Name:
Patient Name:
Patient Name:
Patient Name:
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Address:
I request/authorize the practice listed below to release/disclose Protected Healthcare Information to
Building Blocks Pediatrics, PLLC.
Practice Name:
Address:
City:
State:
Zip Code:
Telephone number:
Fax number:
This request and authorization applies to:
□
All healthcare information
□ Other:
□
Healthcare information related to the following condition, treatment, and/or dates:
Disclosure purpose: ____Coordination of care _____Patient Use ____Legal ___ Other: ____________
The patient or representative may revoke this authorization at any time by notifying the Building Blocks Pediatrics, PLLC
Privacy Officer in writing. This authorization will remain valid indefinitely if no expiration date is specified. Refusal to sign
this authorization will not affect your ability to receive treatment or payment of services. Information disclosed pursuant to
this authorization may be subject to re-disclosure by the recipient that is not protected by federal law.
□Yes □No
I authorize the release of any Sexually transmitted disease results, HIV/AIDS testing,
whether negative or positive, of the person(s) listed above to Building Blocks Pediatrics, PLLC.
□Yes □No
I authorize the release of any records regarding drug or alcohol abuse, or related to mental
health assessments or treatment of the person(s) listed above to Building Blocks Pediatrics.
Please send the requested information to:
Building Blocks Pediatrics, PLLC
3603 Davis Drive, Suite C-201
Morrisville, NC
Phone: (919) 234-1582 Fax: (919)234-1586
[email protected]
Patient/Parent/Legal Guardian Signature:
Printed Name/Relationship to Patient:
Date signed: