Medical Release Form - Incoming

Obtain Medical Records

For PAL to authorize receipt of previous medical records, we must first have a signed authorization form received from a parent or legal guardian.

Authorization to Obtain Confidential Information

I hereby aurthorize Pediatric Associates of Lawrenceville to release/obtain pertinent medical information regarding the above named patient to medical personnel actively involved in the patient's treatment.

I understand that my permission to release this information to the following parties will include sensitive clinical information, which may or may not include treatment of substance or other abuse, HIV, psychiatric disorders, sexually transmitted diseases, etc., unless herein excepted.

This information, which may be released by phone, mail, or fax commas released to:

Pediatric Associates of Lawrenceville

738 Old Norcross Rd, Suite 100

Lawrenceville, GA 30044

Phone: (770) 277 - 6725

Fax: (770) 277 - 9169

Patient Name

Previous Doctor

Please enter contact information for previous pediatrician below.

Name

Address

Phone Number

Pediatric Associates of Lawrenceville is hereby released from all legal responsibility for the release of the records to the extent indicated and authorized herein.

Parent or Guardian

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