AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Pediatric Healthcare Associates

All information must be filled out properly. please allow 15 days for records to be completed. Thank you.

Release Record From:

Physician/Provider:

Address:

City:

State:

Zip:

Phone Number:

Release Records To:

Physician/Provider:

Address:

City:

State:

Zip:

Phone Number:

Patient Information

Patient Name:

Date of Birth:

Address:

City:

State:

Zip:

Phone Number:

Social Security Number:

Please state the reason records are being released:

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.

Parent/Legal Guardian Signature:

Date:

Office Use only:

Date Received:

Provider/Administrator Initials:

Date Copied:

Date MAiled/Pt notified to pickup:

Your information will be encrypted.

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