Full Name *

First

Last

Date of Birth *

Email *

If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

I hereby request that my medical records be released to:

Type of the entity *

Institution (e.g., employer, school, court, landlord)
Person (e.g., psychiatrist, doctor, relative, legal guardian)
Myself

Understands "myself" doesn't allow custom documents *

By chosing the “Myself” option in this form, I understand that I can only be provided a raw copy of my records without any modification and I also understand that I cannot be provided any additional documents that is not already part of my chart as of the date I submit this form.

Raw records may include documents such as diagnosis summary, assessments, progress notes, and chart notes.

Name of the institution *

Write the institution’s full name and avoid any typos.

Phone number of the institution

Fax number of the institution

Email address of the institution

Physical address of the institution

Address Line 1

City

State

Zip Code

Documents requested by the institution (if applicable)

Click or drag a file to this area to upload.

(e.g., FMLA Leave Form, Medical Certification Form)

Full name of the person *

First

Last

Relationship *

(e.g., spouse, parent, child, legal guardian, pcp, psychiatrist)

Phone number of the person *

Email address of the person *

Physical address of the person

Address Line 1

City

State

Zip Code

Notes for us *

(e.g., Purpose of your request, specific instructions, explanation)

Medical Records Release Terms & Conditions *

I read the following disclosure in full and I authorize the release of my medical records to the institution/person I provided in this form.

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.

Correspondence Fee *

I understand that I will incur a $200/hr correspondence fee and I agree to pay this fee for my request(s).

Shaysa Villa is able to provide correspondence (e.g., formal letters, legal paperwork, meeting participation, court participation), if it is deemed clinically fit and appropriate. We hold a strict correspondence policy. Each correspondence document or paperwork will accrue a $200 per hour fee. In addition, it is required that our clients have an established relationship (minimum 12 weekly appointments) with the psychotherapist before agreeing to provide any correspondence.

Please upload photos of your State ID (front and back) *

Click or drag files to this area to upload. You can upload up to 2 files.

Signature *

Clear Signature

Medical Records Request Form

I hereby request that my medical records be released to: