Record Release Authorization

Previous 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

Problem List
Growth Chart
Last 2 Well Check Visits
Full Immunization Record

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.

*FOR CHILDREN 6 MONTHS AND YOUNGER, PLEASE PROVIDE ALL RECORDS.

Add Child

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

Your information will be encrypted.