Patient Request for Medical Records Form Authorization to Disclose/Release Protected Health Information

Please correct the errors described below.

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For Record Release

By signing this authorization, I authorize Gold Pediatrics LLC named above to disclose (PHI) protected health information about myself and/or child(ren) to the entity listed below. It is my right to revoke this authorization at any time, in writing to the address listed below provided the requested information has not yet been disclosed/released.

If provider uses eClinical Works please send records via eCW P2P

Or 15005 Shady Grove Road, Suite 450 Rockville, Maryland 20850

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.

This authorization permits: Gold Pediatrics LLC at 15005 Shady Grove Road Suite 450 Rockville, MD 20850 to use information requested from and disclosed by the above listed Provider/Specialist. I understand that this authorization is valid for one year from the date on which it was signed.**

Your information will be encrypted.