Authorization for Release of Medical Information

Patient's Name:

Date of Birth:

Signature of Parent/Guardian:

Date Requested:

I authorize West Hills Children's Medical Group to:

Mailed

Will Pickup

Faxed

Email address (if selected emailed)

Name of Provider/Parent

Address of Provider/Parent:

City

State:

Zip Code of Provider

Phone Number/Fax Number (Including area code)

Documents Requested

Immunizations Only All Medical Records

Name of Provider

Address of Provider

City

State

Zip Code of Provider:

Phone Number/Fax Number (Including area code)

Documents requested:

Immunizations Only All Medical Records

This authorization is valid for 90 days

Your information will be encrypted.