For PAL to authorize receipt of previous medical records, we must first have a signed authorization form received from a parent or legal guardian.
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
Please enter contact information for previous pediatrician below.
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.
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