Ennis Pediatrics - Request of Medical Records

Patient Name:

Date of Birth:

Please send the following:

History and Physicals

Problem-focused Notes

Radiology Results

Immunization Record

Lab Records

Entire Medical Records

Newborn Nursery Record

Other

If other, Please specify:

Please release my protected health information from the following person / entity:

Name:

Street:

City:

State:

Zip:

Phone:

Fax:

By Signing this form I authorize you to release confidential health information about my child by releasing a copy of the medical records to the entity below.

Please release my protected health information to:

Ennis Pediatric and Adolescent Health Care Center, P.A.

Dr. Katherine Brown, MD, FAAP
Elaine Donet, FNP-BC
Jamie Rowland, CPNP

805 S Clay Street Ennis, Texas 75119 Phone: 972.875.8300 Fax: 972.875 8312

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 / Legal Guardian Signature:

Date:

Your information will be encrypted.