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