Name of Patient(Required)

Date of Birth(Required)

Name of Requestor(Required)

Relationship(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Records(Required)

I hereby request the following information to be released:

Medical Records

Billing Records

Dates of Service(Required)

Pertaining to the following date(s) of service:

Transfer Method

How would you like the records?

I understand that any information provided to me pursuant to this request will not include psychotherapy notes, information complied in reasonable anticipation of (or for use in) a civil, criminal or administrative proceeding, or as may otherwise be required by applicable law.

I understand that Just 4 Kids Health may deny this request under limited circumstances permitted by federal regulations governing the protection of personally identifiable health information. I further understand that, except as otherwise permitted under applicable federal law, I have the right to have a denial of my request reviewed by a licensed health care practitioner selected by the practice who did not participate in Just 4 Kids Urgent Care’s decision to deny my request.

I understand that Just 4 Kids Health will approve or deny my request within 3 business days of receiving this request. If Just 4 Kids Health is unable to comply with my approved request within 3 business days, they will notify me in writing with the address provided.

I understand that Just 4 Kids Health will notify me of any fees for copying, processing, or mailing my records, prior to completing my request.

Signature of Requestor(Required)

Date Requested(Required)

Signature of Recipient(Required)

Date Released(Required)

Records Release

CALL 911 IF YOU THINK YOUR CHILD IS EXPERIENCING A LIFE-THREATENING EMERGENCY.

Idaho Falls

Chubbuck

Rexburg

CALL 911 IF YOU THINK YOUR CHILD IS EXPERIENCING A LIFE-THREATENING EMERGENCY.

Idaho Falls

Chubbuck

Rexburg

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