Specialists Record Release Authorization

Physician

Address

City

State

Zip

Phone

Fax

Please forward records to West Broward Pediatrics

By Email: RECORDS@WESTBROWARDPEDIATRICS.COM

By FAX: 954-424-4200

I authorize and request you to release the following records to West Broward Pediatrics:

Authorization to Release Protective Health Information

I DO authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse. I DO NOT authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection, psychiatric care and/or psychological assessment, and treatment for alcohol and/or drug abuse.

Child's Name

DOB

Parent's or Legal Guardian's Name

Phone

Address

City

State

Zip

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.

Parent/Guardian Signature

Date

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