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I hereby request the following information to be released:
Pertaining to the following date(s) of service:
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.

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