Record Request 1Welcome2Client & Requestor Information3Record Requested4Delivery Method5Signature & Acknowledgement Client Record Request Form Your request for client records will be processed and fulfilled within fifteen (15) business days. Please note that additional processing time may be necessary if records are retrieved from an off-site facility. Records will be provided via the delivery method specified below. Once all records are retrieved, we will notify you of any charges via phone call and provide you with an invoice. Fillable PDF versions of this form are also available in English and Español. Must be signed by a legal guardian or representative. Client Name(Required) First Last Client Date of Birth(Required) MM slash DD slash YYYY Name of Person Requesting Records(Required) First Last Relationship to Client(Required)Contact Phone Number(Required)Your LEARN ProviderChoose ProviderASTBACABCIPrioritiesSPARKSTandem TherapyTotal SpectrumTrellisWEAPOtherOther Provider(Required) Please include copies of (Check all that apply):(Required) Assessment Report Authorizations Formal Correspondences Psychological Evaluations Referral Packet Session Notes Treatment Plans Other Other (Please Specify):(Required) Date of Record(s): Delivery Method(Required) E-mail (No charge) Fax/E-fax (No charge) Mail (You consent to the fee charges below) Note: The Company’s default delivery method is a HIPAA-compliant, fully-encrypted and password protected email sent to the email address on file or indicated on this form. If paper records are requested by mail, the Company will charge a per page fee of 10 cents + US Postage. Additional charges may apply for videotape requests.Recipient DetailsName(Required) First Last Phone Number(Required)Email(Required) Fax Number(Required)Address(Required) Street Address Address Line 2 City(Required)CityState(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateComments (Optional) I understand that I have the legal right, within certain limitations, to either view or obtain copies of treatment plans and related records of my child. I understand that the raw data is clinically analyzed by the staff and should not be misinterpreted. I will direct any questions about the data, reports, and other items to our Program Supervisor.Today's Date(Required) MM slash DD slash YYYY Your Full Name(Required)
