CONSENT FOR RELEASE OF MEDICAL RECORDS

Including HIV, AIDS, & ADD/ADHD, psychiatric illness and related information

1. I hereby authorize

Tel#:

Fax#:

to release the following information from the medical records of:

Patient name:

Birthdate:

Address:

Phone:

Social Security #:

Information to be released:

2. Copy of complete medical record, including any testing, evaluation, treatment or correspondence, including those records related to ADHD and/or psychiatric illness.

3. Any and all records, tests, or diagnosis of treatment for HIV, HIV-related illness, AIDS and any other communicable disease related illness.

4. Hospital Records, Emergency Room visit report, Specialist Office visit correspondence, laboratory studies and x-ray reports for the following date(s).

Information is to be released to:

Specify date(s):

Mt. Airy Pediatrics, PC
6673 Germantown Ave.
Philadelphia PA 19119-2252
Tel# 215-247-2996/Fax# 215-247-7504

5. I understand this consent can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on this consent and is valid for one year from date of signing. It can be revoked at any time.

6. The facility, its employees and officers and attending physicians are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

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

Parent/Patient/Guardian Signature:

Relation to Patient:

Date:

Witness:

Date:

Your information will be encrypted.