Authorization to Obtain Medical Records

Date:

Add another patient

I hereby authorize: PediaGroup Associates to Obtain:

Name of Doctor/Facility:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Medical Records being requested:

All Medical Records

Vaccine

Radiology

Other

Reason for Request:

Relocated:

Insurance:

Other:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Parent Signature:

Date:

Your information will be encrypted.