Welcome to Beyond-Limits

Authorization to Release Medical Records and Protected Health Information

Welcome

About 3 minutes 6 steps Sent securely

Language assistance services and appropriate auxiliary aids and services, including information in accessible formats, are available to you free of charge. Call 770-917-5737 (TTY: 711) or speak to your provider.

Questions marked * are required.

Patient Information

PATIENT NAME

DOB

Please enter a date that isn't in the future.

Address

Request and Release of Medical Records

A) I authorize BLPTC to RELEASE my child’s medical records to:

B) I authorize BLPTC to OBTAIN my child’s medical records from:

Information to Be Released

Please check information that may be released. (Please note that only records that have been ordered by our office will be released.)

All records (will include Audio, ST and OT Evaluations, Plans of Care and Office Notes)

Evaluations

Plans of Care

Office Notes

Delivery of Records

These records are to be:

Picked up

Mailed to

Faxed to

Emailed to

Authorization and Signature

I hereby authorize this practice to release my medical records, including, but not limited to all of the above. By signing this consent, I completely release the entity, facility, or medical practitioner from any and all liability which may result or could result from the release of such information. I also understand this authorization is only valid for 12 months. However, I reserve the right to revoke this authorization at any time.

SIGNED

DATE

Printed Name

relationship to patient

Street Address

City, State, Zip Code

contact number

Please enter a 10-digit phone number.

Witness

WITNESS

DATE

Printed Name

Beyond Limits Pediatric Therapy Center/Beyond Limits Audiology