Medical Release Form - Outgoing

Release of Information

For PAL to authorize release of confidential Protected Health Information, we must first receive a complete, signed release from a parent or legal guardian.

Authorization to Release Records

I hereby authorize Pediatric Associates of Lawrenceville to release pertinent medical information regarding the below named patient or patients. I understand that my permission to release information will include treatment of substance or other visas, HIV, psychiatric disorders, sexually transmitted diseases, etc., unless herein excepted.

Patients Information

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

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.