Release of Records from BPMG Authorization to Release Medical Records

I hereby authorize Berkeley Pediatric Medical Group:

Physician’s Name

to release medical records, including immunizations, concerning:

Add Patient Name

To:

New Physician’s Name (Print)

Address

City

State

Zip

Phone Number

Fax Number

Reason for Request

Transferring care

Change of Insurance Coverage

Moving

New address

Records include a summary of care, immunization records, growth charts and pertinent medical information specific to your child. By signing this authorization, I give permission for BPMG to release and transfer my child’s protected health information to the above physician for the purpose of treatment. I understand that this authorization is in effect for one year from the date signed.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Parent/Guardian’s Name

Relationship to Patient

Your information will be encrypted.