Medical Records Request & 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).
Below you’ll find instructions for completing the “Release of Information” form which 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 to ensure that the authorization is accurate and complete. If you have any questions or concerns, please call us at 920.750.7000.
1. Patient Information
Please provide the patient’s legal name and date of birth. If you or your child have been seen under another name in the past, it is important that you note all previous names so we can locate 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. You may also add an email address for the person or organization you identify; but this is optional.
Please note: you can use this same form to request a non-Catalpa healthcare provider to send records to Catalpa.
3. Identify the type of information to be disclosed/accessed
Identify exactly what type of information you want copied or are otherwise permitting the person you designate access to. Checking each box grants access to each type of document contained in your/your child’s medical record.
- The “Behavioral Health Records” box must be checked in order to access or permit access to any Catalpa Health records or to request Behavioral Health records from an outside organization/provider.
- The “Medical Records” box refers to records that are not of a behavioral health nature, but rather for primary care or other non-behavioral health specialty records.
- The “Pupil and Educational Records” box refers to records created at and received from a school or other educational facility and should be checked each time records of those nature are to be requested.
Please speak with a member of the Medical Records team directly at 920-750-7033 for additional information on these boxes or any of the others listed on the form. Catalpa Health will never re-release another organization’s records, including school records, to anyone including the patient/patient’s parent or legal representative.
4. Specify the period of time covering the records to be accessed/disclosed
Options are to select:
- All | Checking the “all” box will cover all dates of service including information created after the date of signature, but prior to the date of expiration.
- From: _______ To: _______ | Checking this box and adding a date range allows you to designate a specific range of dates that may exclude certain periods of time or records created outside of the specified date range.
5. Identify the purpose of disclosure
Please check the box that most closely identifies the reason you are completing the form.
6. Specify an expiration date
Complete this area if you would like to note a specific date or event of expiration.
Leave this area blank to use the default expiration of either the patient’s 18th birthday if the patient is under the age of 18, or one year from the date of signature if the patient is age 18 or older.
7. Your rights
Under federal and state law, the authorization form must contain a section addressing your patient rights with regard to the form. These rights are found at the bottom of the release form. Please review these prior to signing and contact a member of the Medical Records team if you have any questions or concerns regarding these rights.
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 will be considered valid. If the patient is incompetent, a minor or has passed away; the patient’s legal representative may sign on their behalf, but will be asked to provide proof of legal status.
Adding your signature and date acknowledges you have read the Patient Rights on the form, and have the legal ability to sign the form and, if you are the custodial parent of the patient, have not been denied physical placement of the patient; as there are regulatory privacy protections impacting access by a parent who has been denied physical placement of a child.