Request for Record Release

REQUEST FOR RECORDS RELEASE OF MEDICAL RECORDS AUTHORIZATION

I hereby authorize:

Physician’s Name (Print)

Phone Number

Address

City

State

Zip

to release medical records, including immunizations, concerning:

Patient’s Name

Date of Birth

Add new name

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

To: Berkeley Pediatric Medical Group

1650 Walnut Street, Berkeley, CA 94709

Phone: (510) 848-2566

Fax: (510) 848-2503

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

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.

Printed Name/Signature

Date

Relationship to Patient

Your information will be encrypted.