Transfer to us

Please correct the errors described below.

Including HIV, AIDS, & ADD/ADHD, psychiatric illness and related information ***PATIENTS 18 YEARS OR OLDER MUST SIGN THEIR OWN RELEASE*** 1. I hereby authorize Mt. Airy Pediatrics, to release the following information from the medical records of:

Information to be released:

If you request to pick up copies of your records at our office, we will only keep the copies in our current pickup file for 8 weeks and then they will be mailed to the home address we have on file for you. 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. 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.

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