Release of Records from BPMG Authorization to Release Medical Records

I hereby authorize Berkeley Pediatric Medical Group 1650 Walnut St., Berkeley, CA 94709

Dr. Annemary Franks
Dr. Katrina Michel
Dr. Olivia Lang
Dr. Nicole Learned
Dr. Lisa Kalar
Dr. Samuel Woods
Dr. Grace So

to release medical records, including immunizations, concerning:

Patient’s Name

Date of Birth

Add new name

Physician’s Name

Address

City

State

Zip

Phone Number

Reason for Request

Transferring care

Moving

Change of Insurance Coverage

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.

Printed Name/Signature

Date

Relationship to Patient

Your information will be encrypted.