M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

Records Request Personal Use

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION: MEDICAL RECORD RELEASE TO PARENT OR GUARDIAN

Patient Name *

First & Last Name

Date of Birth *

Patient Date of Birth

Parent/Guardian Name *

Type YOUR NAME if your are over 18 and requesting for yourself.

Address *

Phone *

To notify you of the completion of your request

Email or Fax *

TO DISCLOSE THE FOLLOWING INFORMATION: *

All Records Pertaining to the Treatment of the Patient

Specific Dates of Service Needed (Please indicate below)

PURPOSE OF DISCLOSURE: At the request of the individual/legal guardian: *

I understand that any disclosure of health information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules.

I understand that there is a charge for obtaining my child?s records of $0.50/page for the first 50 pages and $0.25/page for all additional pages.

I understand that I have the right to revoke this Authorization at any time, except to the extent action has been taken in response to this authorization, by giving written notice of revocation to the practice at the address noted above. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

The written revocation must be legible and include the name and date of birth of the individual, the date the revocation is to go into effect, a description of the health information covered by the revocation, the person/entity no longer authorized to the receive the information, the signature of the person with legal authority for authorization/revocation, and if not the individual, a description of their legal authority for authorization/revocation, and their phone number.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility for benefits.

By checking this box I certify that I am the patient or legal guardian with the authority to authorize disclosure of this individual?s protected health information. *

I Agree

Patient/Guardian Signature *

First & Last Name

Today's Date *

Unless otherwise revoked in writing, this authorization will expire two years from the signature date.

* Required field