Authorization for Release of Medical Records

For this authorization, "My Health Information" is;

Complete Record

Immunizations

Specific Notes

Labs

Limited Records

(Growth Chart, Immunizations, Lead Results, and Last Physical)

If specific notes, please explain:

For the date starting:

through:

I hereby authorize ____________ to disclose my health information

to Peds in a Pod Pediatrics

1105 North Point Blvd

Suite 306

Baltimore, MD 21224

Phone: 410-285-5437

Fax: 410-285-7333

Reason for Release:

Transferring Primary Care

Specialty Appointment

Other

If other, please specify:

I understand that this authorization gives my parent/legal guardian permission to release any Protected health information (PHI) that is contained in the Medical Records including information and records or copies of records relating to the history, diagnosis, treatments or services rendered to me in connection with any condition or disease. This includes information concerning my treatment of mental illness, Human Immunodeficiency Virus (HIV), alcoholism, drug use/dependency, venereal disease, sexual assaults, abortion, the illegitimacy of birth, communications to social workers and/or psychotherapies, psychologists, if any.

I release Peds In A Pod Pediatrics, LLC and the Recipient/Discloser listed above, and any of their providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to Peds In a Pod Pediatrics, LLC, provided that I do so in writing and to the extent that you have disclosed the information in reliance on this authorization.

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

This authorization will expire on

Patient Name

Date of Birth

Parent/Guardian Signature

Date

Printed Name

Relation to Patient:

Your information will be encrypted.