Authorization for Release of Medical Records - Pediatric Practice

Patient Information

Child's Full Name: _________________________________ Date of Birth: //___ Previous Names (if any): ___________________________ Medical Record #: ________

Parent/Legal Guardian Information

Name: _________________________________________ Relationship: ____________ Phone: ________________________________________ Email: _________________

Release Records

From:

Provider/Facility Name: ____________________________ Address: _______________________________________ Phone: _________________ Fax: __________________

To:

Provider/Facility Name: ____________________________ Address: _______________________________________ Phone: _________________ Fax: __________________

Information to be Released

• Complete Medical Record
• Immunization Records
• Growth Charts
• Laboratory Results
• Imaging Reports
• Clinical Notes
• Other (specify): ______________________________

Date Range

From: //___ To: //___

Purpose of Release

• Continuing Care
• Personal Records
• Insurance
• Legal
• Other (specify): ______________________________

Authorization

I understand that:

• This authorization is valid for 90 days from the date of signature
• I may revoke this authorization at any time by submitting a written request
• Treatment is not conditional upon signing this authorization
• Once information is released, it may be redisclosed and no longer protected by HIPAA

Signature: _____________________________________ Date: //___

Printed Name: __________________________________ Relationship: ____________

For Office Use Only: Date Received: //___ Processed By: __________ Date Completed: //___