Medical records of a sensitive nature (mental health, HIV status, pregnancy status, etc.) must NEVER be faxed. Also, records should never be faxed to a parent or guardian. If it is necessary to fax records to another physician, only the information needed (i.e. Records for a referral visit) should be faxed and a “confidential” fax cover sheet must be used. The patient, or other person authorized to provide consent, has the right to withdraw consent for the release of information at any time. Such withdrawal must be in writing. No information can be released after consent has been withdrawn.

Records Release Forms

Please download the appropriate form above, fill it out and e-mail it to forms@knoxpeds.com. Thank you!

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Medical Records Release

Records Release Policy

Copies of medical records may be released to the patient or another individual only with specific written authorization from the patient or the patient’s legal representative. All requests for the release of medical records to the patient or an attorney will be brought to the attention of the office manager and/or treating physician.

Note: The records release authorization form must be completed in its entirety. A copy of the authorization must be maintained in the patient’s medical record. A separate form MUST be completed and signed for each child/patient. Records may be released to both the custodial and non-custodial parents.

Records may also be released to a guardian other than the parent. However, proof of guardianship must be provided before records can be released. If this is the case, the information must be notated on the account. Before any records can be released, a drivers’ license or photo ID must be presented (the ID number must be notated on the records release form). A patient who is 18 years of age or older must sign for his/her own records to be released. Again, a picture ID must be presented before records can be released.

There is a charge for all records released. The fee is $20 for the first five (5) pages of the medical record and a per page charge of $0.50 for all pages thereafter. There is NOT a charge to release records directly to another physician. The amount charged must be notated on the records release authorization.

Psychiatric/Substance abuse patients: Federal regulations require confidentiality for all records of the identity, diagnosis, prognosis or treatment of any patient maintained in connection with any activity or program related to alcohol or drug abuse, including education, training, treatment, rehabilitation, etc. Any individual who has a primary or secondary psychiatric diagnosis or who has a diagnosis of or received treatment for alcohol or drug abuse is covered under these regulations. This type of information is extremely sensitive in nature. A signed authorization from the patient or patient’s legal representative must be in the chart before such information can be released to anyone, except when the law mandates disclosure, as in cases of public record, public health and Department of Human Services.

HIV/AIDS Patients: “AIDS Confidential Information” (ACI) discovered or disclosed within the patient-physician relationship shall be confidential and shall not be disclosed except by State law or by written consent from the patient or patient’s legal representative.

A. Any information that identifies a person and disclosed the following is protected under the Federal Regulations for ACI:

  1. that an HIV test was done (regardless of result)
  2. that the patient was at risk for infection with HIV/AIDS
  3. determination that the patient is infected with HIV
  4. that counseling was sought or received regarding HIV/AIDS
  5. a diagnosis of AIDS, and
  6. treatment of AIDS

B. Any such request for ACI should be referred to the attending physician prior to the release.