A Requestor's directions for completing KidsPeace Release of Information Form
Please ensure the following items are completed:
- Client's Name
- Client's Date of Birth
- Name, address, telephone number of individual and/or Company the documents requested will be going to
- Purpose - please provide the reason for the request of documents
- Information to be RELEASED is:" - please check ALL document type being consented to be released
- Effected to and from dates, please put in DD/MM/YYY format
- Check "yes" or "no" if the individual signing to release the documentation wishes to review the documentation prior to KidsPeace forwards the documentation
- If "yes", a separate Release of Information Form would need to be completed to release the information to yourself. Please note there would be a charge per page.
- Clients age 14 and over: would need to sign the form
- Clients under the age of 14: the parent of legal guardian needs to sign the form
- Witness signature
- Print the completed form. Either fax to 610-799-8820 or mail to Medical Records | National Headquarters | 4085 Independence Drive | Schnecksville, PA 18078