Request for Record Release

REQUEST FOR RECORDS RELEASE OF MEDICAL RECORDS AUTHORIZATION

I hereby authorize:

Physician’s Name (Print)

Address

City

State

Zip

Phone Number

Fax Number

to release medical records, including immunizations, concerning:

Add Patient Name

(Our office is on EPIC EHR through UCSF. Please contact our office if we can request the records electronically through EPIC.)

To:

Berkeley Peds Physician’s Name

By signing this authorization. I give permission to release and transfer my child’s protected health information to the above requesting doctor 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.