Medical Records Request

Medical Records Department

Standard copying and clerical fees are payable to the Medical Records processor prior to the release of all medical records. Records will be mailed by standard US mail to the mailing address on file for patients. Records are not faxed or available on a walk in basis. Please refer to the full Medical Records policies for further details. Kindly contact the records processor if you have not received your records by 15 days from the date of payment and submitted written request and authorization.

Payment is accepted via secured Paypal or credit card.

AMOUNT

All records requests require a $50 clerical fee and $0.25 per page.

Please include number of pages of records requested. A discounted one time request of $35 plus $0.25 per page is available for properly submitted initial requests.

Incomplete medical record request forms and failure to submit proper payment and signature will result in cancellation of your medical record request.

Medical Records Department

26081 Merit Circle, Suite #109

Laguna Hills, CA 92653

Phone (949) 582-7699 Fax (949) 582-7691(rev 08/10)

RECORDS POLICY

FAQ’s:

· Are records available directly from your office?

No. Medical records are available only through the Medical Records Department and Certified Processor.

· How many days will it take to get my records?

Processing of records may take up to a maximum of 15 days. Rush requests may be accommodated but not guaranteed.

· Can I just call in for my records?

No. A properly completed written and signed record request is required for all record releases.

· Am I entitled to free medical records?

No. Record Fees are $50 plus 25 cents per page and payable in advance.

· Can I get a discounted price for my records?

Yes. A discounted initial record request of $35 plus 25 cents per page may be extended to you as a one time courtesy for a prepaid and properly filled out request. Requests that have to be sent back for completion or payment will not be eligible for the courtesy discount.

· Were records provided for free before?

Yes. There has been a charge for all records for more than one year.

· Is charging for medical records standard policy?

Yes. This policy is in accordance with California Health & Safety Code section 123110. Pre-payment must be processed prior to mailed release of records.

· What if I am seeing another doctor?

All record requests are processed through the Medical Records Department and carry a fee.

· Can you bill my insurance for my records?

No. Insurances require patients to self pay for medical records.

· Can I have my records faxed?

No. To ensure full privacy, records are not faxed or available on a walk-in basis.

Medical Records Department

26081 Merit Circle, Suite #109

The Skin Center Laguna Hills, CA 92653

Phone (949) 582-7699 Fax (949) 582-7691(rev 08/10)

MEDICAL RECORDS RELEASE & FEE AUTHORIZATION

Patient NAME __________________________________________________________________________

Birth date: ________________________ Last 4 digits Social Security #:XXX-XX- _ _ _ _

My Phone #: _________________________ My Fax #: _______________________________

Records to be mailed to my home address:

Address City State Zip

What records are requested? (Be sure to specify actual dates below)*FEE $50+ 25cents/page applies

□ Most recent labs □Most recent pathology report □All pathology reports

□All Records □Other: ____________________________________________

Reason For Records Request :

□ Personal records □ 2^nd opinion □ Plastic Surgery □ Other:__________________ ______

□ Permanently transferring care? Please, note reason:__________________________________________

□ Moving/moved out of the area; please provide your new address and phone number:

Address City State Zip PHONE

I understand that someone from the medical records department may be contacting me to by telephone, fax, or mail to verify the information that I provided above. I hereby affirm that I am the person listed on this request. To comply with federal laws and protect my medical privacy, my signature and identifying information will be verified.

I understand that the authorization for release of records as detailed above, unless specifically limited by me in writing will extend to all aspects of treatment provided at The Skin Center. These records may include testing for all sexual transmitted diseases, AIDS, and hepatitis, as well as drug, alcohol and/or psychiatric information.

I understand that records are processed within 15 days of the date of the received written request. Medical records are not available on a walk-in or same day basis. All requests must be in writing and are handled by standard ground mail. Records are not faxed (to non-verified numbers). It is policy that a clerical copying fee of $50.00 plus $0.25 for each page printed, for the printing of patient medical records through the medical records department. This is in accordance with Health & Safety Code section 123110. Pre-payment must be processed prior to mailed release of records. I can choose payment by credit card, money order, or cashier’s check, Paypal (to Billpay@theskincenter.org), or online at www.aderm.us.

I AUTHORIZE $________PAYMENT TO BE CHARGED ON CREDIT CARD BELOW: □VISA □MASTERCARD

CARD # EXPIRATION DATE: BILLING ZIP CODE:_______

I hereby release The Skin Center from all legal responsibility of liability for the release of the above disclosure of information. I understand that I have the right to withdraw this authorization at any time and that such revocation must be in writing. I agree that it is my sole responsibility to contact The Skin Center is I have not received my records by 15 days. I understand that incomplete forms received without proper payment will be considered invalid, thereby causing a cancellation of or delay in processing of my records request.

Date:__________________ Signature:______________________________________________

THE SKIN CENTER

Providing Excellence in Board-Certified Medical, Surgical, Cosmetic and Pediatric Dermatology.