Request for Release of Burgess Pediatrics’ Medical Records

By signing this form, I authorize Burgess Pediatrics to release confidential health information about my child(ren), by releasing a copy of their medical records to the physician/person/facility/entity listed below. I acknowledge that Burgess Pediatrics cannot be responsible for maintaining the confidentially of this data once it leaves this office. This authorization to release confidential medical records is required by state and federal law.

Release copies of the medical records of:

Date of Birth:

Including:

Medical evaluations

Vaccination history

Growth records

Radiology reports

Lab reports

Release my child(ren)’s protected health information to the following:

Physician name and Clinic:

Name of Person:

Address:

Phone:

Fax:

Name of individual requesting records release:

Relationship to patient:

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.

Signature:

Date:

Your information will be encrypted.