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Medical Records
AUTHORIZATION FOR RELEASE
An Authorization for release of confidential information is a written statement from the individual or the individual’s legal guardian; or in the case of a minor, the individual’s parent/legal guardian; who authorizes the disclosure of all or part of the medical record of the individual.
Authorization for Release of Your Medical Record
Requests for copies of your Pineland BHDD CSB medical records must be made in writing, must include your original signature, and must be hand delivered, mailed, scanned or faxed to a Pineland CSB service unit. You will need to complete our Authorization to Release Protected Health Information (PHI) Form. If you are actively receiving treatment, your physician must sign to authorize the release for family involvement or personal use. Proper identification will be required to pick up medical records.
FEES
Payment will be requested prior to the release of the information.
Charges are as follows:
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Effective:
July 1, 2018
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Search, Retrieval & Other Direct Admin Cost
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Up to:
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$25.88
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Certification Fee
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Up to Per Record:
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$9.70
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Copying Costs for Records in Paper Form
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Per Page for Pages 1-20
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$0.97
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Per Page for Pages 21-100
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$0.83
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Per Page for Pages over 100
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$0.66
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- The following schedule of charges applies to disability adjudication requests:
- Standard paperwork - $10.00
- Mental Impairment Questionnaire - $20.00
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