RELEASE OF MEDICAL RECORDS

I request that:

(Designated physician, person or entity)

(Address)

(City) (State) (Zip)

(Telephone)

(Fax)

Release the COMPLETE MEDICAL RECORDS AND IMMUNIZATIONS of the following patients:

(Please list the full names of all children whom you are requesting records for)

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Select PCP Selection:

Dr. Megan Ference, MD Dr. Reshma Chugani, MD

Date

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

(If minor, signature of parent, guardian, or custodian)

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*** This office will not schedule any new patient appointments until complete medical records are received from the previous physician's office for coordination of care, we are not contracted with any Medicaid insurance policies (Ex. CareSource, Peachstate, Amerigroup, etc) Please confirm that we accept your insurance. ***

Internal use only.

Date Received:

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