Authorization to Release Medical Information

Authorization to Release Medical Information

Document Types Requested

Please specify the Document Types Requested if different from All Medical Records.
I hereby Authorize Sweetgrass Pediatrics to Release information to the Recipient listed above.
Please upload your Photo ID for proof of who is completing this form.. Only PDF, PNG, and JPG file types are accepted.

Note: The charge for this service is $15.00 per person. Patients will be charged for a personal copy or for the transfer of their records, as stated in the Financial Agreement signed by all patients. Fees charged are in accordance with Physicians Patients Medical Records Act SC Code Ann. 44-115-80. I understand that any and all information may be released, including but not limited to mental health records protected by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records, and/or HIV test results, if any, except as specifically listed above. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire one year from the signature date above. For the release of records (1) protected by the Lanterman-Petris-Short Act (LPS) or (2) containing HIV test results, a separate authorization is required for each separate disclosure. Further, the LPS Act often requires that both patient's treating physician and the patient sign the authorization form before information may be released. It is unclear whether the beneficiary or personal representative of a deceased patient can obtain and disclose certain records containing HIV test results.