Medical Records Request & Catalpa Release Form
As a custodial parent, court-approved legal guardian or legal custodian, you have the right to access your child’s medical records as well as the ability to permit another person to participate in your child’s care by scheduling and attending appointments in your absence, making a medication refill request and communication with your child’s provider(s).
Here you’ll find instructions and the release form that allows you to make a request for copies of records or provide permission for someone else to participate in your child’s care. Please follow the instructions carefully below to ensure that the authorization is accurate and complete.
Only one person or agency can be noted on each form.
1. Patient Information
Please provide the patient’s legal name and date of birth to help us make sure we have the correct patient. Please leave the MR# blank as it is for internal use only. If your child has been seen under another name in the past, it is important that you tell us that so we can copy all available information.
2. Identify who the authorization is for
Identify the person or organization for which you are authorizing disclosure to, obtaining from or both. If you are completing the release to obtain your child’s records for your personal use, please put your name, address and telephone number. If you are using the form to provide permission for another person to schedule and attend appointments with your child, please put that person’s name, relationship to the child, address and telephone number.
Please note you can use this same form to request a non-Catalpa healthcare provider to send records to Catalpa.
3. Specify the period of time the release will be valid for and confirm an expiration date
Options to select are:
- From: Date of Birth | To: Expiration below (indicate expiration at the bottom of the form)
- From: specific start date | To: specific end date (range needs to be written in)
- If you choose this option, it may be for a specific time period for records.
- Leaving the ‘From’ and ‘To’ blank will permit the widest range of treatment information but you may choose any range of dates you feel is best. If no dates are specified, all dates will be covered through expiration; including information created after the date of signature – but before the expiration. *This is the best option if you want the widest range.
If the patient is over age 18 you may want to put a specific end date or authorize through a specific expiration date at the bottom of the form.
4. Identify the type of information to be disclosed/accessed
Please help us identify exactly what type of information you want copied or are otherwise permitting the person you designate access to. There are many different forms in a medical record and if we can target specifically what you want, we can avoid unnecessary copies.
Checking each box grants access to each type of document contained in your child’s medical record, but may not be included in a disclosure.
For example, Pupil and Educational Records, Behavioral Questionnaires and other screening tools used by Catalpa’s providers to evaluate and provide treatment as well as records created at other facilities such as schools or other clinics are subjected to copyright and additional privacy laws and will not be released. Email messages are not put into a child’s medical record. Any information pertinent to treatment will be documented by the clinician in the appropriate encounter type within the medical record and the email message will be securely discarded.
If you need a more specific description of each box, please click this link.
5. Identify the Purpose of Disclosure
Please check the box that most closely identifies the reason you are completing the form.
6. Your Rights
Under federal and state law, the authorization form must contain a section addressing your patient rights with regard to the form.
The release form will automatically expire on the patient’s 18th birthday unless you choose an alternative date or action event.
Please note: the date you choose may not go beyond the patient’s 18th birthday. If you are the patient and are age 18 or older, please choose a specific future date. (for example, one year from the date you are signing it.)
8. Signature of the Patient/Patient’s Legal Representative
This section must be completed by a custodial parent, court-approved legal guardian, legal custodian, or competent patient on the patient’s own behalf before the authorization can be processed or considered valid. If the patient is incompetent, a minor, or has passed away, then the patient’s legal representative may sign on his or her behalf.
Please note that there are regulatory privacy protections impacting records of minors who are treated for certain conditions. Upon completing this form, please forward the Health Information Management/Medical Record Department of the organization to which you are requesting copies.
If you have any questions, please contact us for further assistance. Thank you!
Print, Complete and Mail/Fax to:
Attention: Medical Records
4635 W. College Avenue
Appleton, WI 54914
Fax: (920) 882-0857