Authorization for Release of Medical Records

Peds in a Pod Pediatrics, LLC

Please correct the errors described below.

to Peds in a Pod Pediatrics

1105 North Point Blvd

Suite 306

Baltimore, MD 21224

Phone: 410-285-5437

Fax: 410-285-7333

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.

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