JUST FOR KIDS PEDIATRICS, PLLC

Transfer of Medical Records Authorization

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AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION

TO: Just For Kids Pediatrics 418 Park Grove Dr. Katy, TX 77450 Phone: 281-492-0774 Fax: 281-492-0716

FROM: Just For Kids Pediatrics 418 Park Grove Dr. Katy, TX 77450 Phone: 281-492-0774 Fax: 281-492-0716

I hereby authorize you to release information including the diagnosis and records of any treatment or examination rendered to the patient during the period from (Start Date) to (End Date) to Just for Kids Pediatrics. I am aware that the records released may contain information relating to psychiatric or psychological testing, physical testing, physical abuse, or drug and alcohol abuse, HIV/AIDS.

I, the parent/guardian, agree that a photocopy or facsimile (fax) of this authorization may be considered valid, and that this authorization can be revoked in writing at any time. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless Just For Kids Pediatrics, from all liability and damages resulting from the lawful release of my protected health information.

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