Medical Record Release Forms
(HIPAA Use & Disclosure for first-time patients only). The following patient forms can be completed prior to your appointment to save you time. These documents are fillable PDF files. They can be printed and filled out manually or downloaded to your computer, filled out electronically and then printed to be brought with you on the day of your appointment.
Permission to Treat without Parent or Legal Guardian Present
Capital Women’s Care must receive permission from a child’s parent or legal guardian before providing treatments for an injury or illness that is non-life threatening. This form gives us legal permission to treat your child in case you cannot accompany them to the practice for treatment.
- A parent/legal guardian must attend a minor’s first visit at Capital Women’s Care.
- A “Permission to Treat a Minor without a Parent/Guardian Present” form is required for a minor to be seen without his/her parent/legal guardian.
- In certain circumstances, in accordance with State and Federal laws, parent/guardian permission may not be needed for adolescents being seen for concerns of “heightened sensitivity” such as STD testing, family planning, or mental health
Medical Record Release Policies
Federal and State law requires the patient’s signature, or that of an authorized personal representative, to release or transfer medical records. The patient records are defined as all records that relate to the health of the patient and are prepared by or under supervision of a health care provider associated with Capital Women’s Care. We maintain the patient’s rights to keep all medical records confidential according to all federal and state laws.
Please note that in some cases, a fee will be charged for medical record copies. The medical record department will be happy to provide you information about fees, expected turnaround times and other information related to your request.
Patients that provide records from another physician, outside of CWC, are encouraged to retain their own copy as Capital Women’s Care cannot provide a copy.