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Medical Records Request Form

I hereby request that my medical records be released to:

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.
Roamers Therapy is able to provide correspondence (e.g., formal letters, legal paperwork, meeting participation, court participation), if we deem it clinically fit and appropriate. We hold a strict correspondence policy. Each correspondence document or paperwork will accrue a 150.00 per hour fee. In addition, we require our clients to have an established relationship (minimum 12 weekly appointments) with their psychotherapists before agreeing to provide any correspondence.
Click or drag files to this area to upload. You can upload up to 2 files.