Authorization of Release of Information

Patient Name

Date Of Birth

Mailing Address

I, the undersigned and being a parent, guardian, or otherwise due authorized caretaker, authorize release of the entire medical record of the above named patient to Kidology Pediatrics, PLLC for the purposes of medical care. I request that those records be released in CCDA format and submitted to Kidology Pediatrics, PLLC via via encrypted email to info@kidologypeds.net or Fax to our office at 248-918-2609

Medical Record Request From Former Doctor or Hospital

Practice or Hospital Name:

Former Physician Name:

Address of Former Practice:

Phone Number:

Fax Number:

I understand:

That I have the right to revoke this authorization at any time by email from an associated email address to info@kidologypeds.net and
That this authorization, unless revoked, will remain in effect until the patient reaches the age of majority.

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 or guardian signature

Date

Your information will be encrypted.