Medical Records Request CommentsThis field is for validation purposes and should be left unchanged.Client InformationClient Legal Name* First Last Maiden or Other NamesClient Birth Date* MM slash DD slash YYYY Client Social Security Number*Requested Medical Record InformationProtected Healthcare Documents to be Released* Discharge Summary Biopsychosocial Level of Care Assessment Treatment Plans Progress Notes Billing Statements Targeted Case Management Documentation Name of the Transformations Provider who Administered and Documented Services to the Client*Start Date of Requested Documents* MM slash DD slash YYYY End Date of Requested Documents* MM slash DD slash YYYY Purpose of RequestWhy are you requesting to share your medical records with someone else?* Continued Care with another Healthcare Provider Personal Interest Legal Purposes Insurance Purposes Disability Determination Vocational Rehabilitation Other What is the purpose of your request?Recipient of the Medical Records InformationWho is the person and/or agency who will be receiving the medical records?* First Last Role or Relationship to Client*Name of the Organization (If Applicable)Address of Recipient* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number of Recipient*Email Address of Recipient* Delivery Options and ChargesHow would you like the records to be delivered?* Email – I understand there is no charge for first request. Repeat requests will incur a charge per request. US Mail - I understand that paper copies will be charged per page and the hourly wage for making the copies. Fees will apply for postage, delivery and thumb drives. Do you require these records to be notarized?* No Yes-I understand that notarized records will incur an additional fee AgreementI understand that the requested records are secure and protected healthcare information but that once they are received by the recipient through email or US mail, the responsibility for their security lies with the recipient. Transformations will no longer be liable for their protection and confidentiality.* Yes I hereby affirm that I am providing true and accurate information and that I have read and fully understand the above statements and consent to the disclosure of the medical record for the purpose and intent indicated. I affirm that I am legally eligible to sign this document and authorize the release of this client’s protected healthcare information.* Yes Click here for additional explanation of practices and services Person Authorizing the Release of Medical RecordsSignature of Client or Legal Guardian*Name of Person Signing* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address* Phone*Relationship to Client* Self-I am an adult client requesting the release of my own medical records I am a custodial parent with joint legal custody. I understand that I must provide custody documents. I am a parent with sole legal custody. I understand that I must provide custody documents I am a court ordered legal guardian of the client– I understand that I must provide a copy of an order of appointment signed by a judge granting guardianship of the client. I am the biological parent of my minor child with no custody order. I am the adoptive parent of the minor child. I understand that adoptions that occurred during or after the termination of treatment may require legal adoption documents. Other What is your legal relationship to this client?Date of Signature* MM slash DD slash YYYY Upload a legal photo identification card of the person(s) requesting thie release (REQUIRED)*Max. file size: 32 MB. Upload a copy of legal documents supporting legal relationship to the client.Max. file size: 32 MB.
