Release of Medical Records

To increase safety and to reduce contact, we are asking you to request electronic copies of your records or send records to us via email. You can email all incoming records to ROIRequests@4securemail.com. Thank you

Record Release

From To

New/Old Physician's Name

Address

City

State

Zip

Phone No.

Fax No.

Record Release

To From

Pediatric and Adolescent Medicine
1190 Baker Street, Suite #103
Costa Mesa, CA 92626
949.999.8106 FAX or
ROIRequests@4securemail.com

Dr. Alyse Baron

Dr. Bette Carlson

Dr. Peri Gunay

Dr. Alison Mann

Dr. Kristin Pelinka

Dr. Jeffrey Taylor

Please release medical records on the following patient(s): Including but not limited to immunizations, office notes, growth charts, consult letters, labs, and procedure results.

Child's Name

Date of Birth

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:

(Parent or Legal Guardian if patient is under age 18)

Date of Birth

This authorization expires

Reason for Request

Change in Insurance

Moving

Changing physicians/continuum of care

If changing Physician/continuum of Care, select one

physicians continuum of care

For existing patients, do you have any feedback you’d like to share with our office before you leave?

Please NOTE: We do not charge a fee for one-time transfer of medical records to a physician, or for a parent’s request for 1-2 pages from the chart. $30 flat rate charge for records produced as a multi-page PDF on a CDR, or for a full set of records requested because of outdated technology. A small number of copies can be requested at an additional rate of 0.25 per page. All requests will be processed by Integrated Business Solutions and payment to be made payable to them.

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.

Patient's Name / Siganture

Date

Revised 4.17.2024

Your information will be encrypted.

Release of Medical Records

Pediatric and Adolescent Medicine1190 Baker Street, Suite #103Costa Mesa, CA 92626949.999.8106 FAX orROIRequests@4securemail.com

Pediatric and Adolescent Medicine
1190 Baker Street, Suite #103
Costa Mesa, CA 92626
949.999.8106 FAX or
ROIRequests@4securemail.com