Release of Records from BPMG Authorization to Release Medical Records

Please correct the errors described below.

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:

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Physician’s Name

Reason for Request

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.

Your information will be encrypted.