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

For Record Release

By signing this authorization, I authorize the entity entered below to disclose (PHI) protected health information about myself and/or child(ren) to Gold Pediatrics LLC. 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.

Previous Provider/Specialist

Street Address:

City:

State:

Zip Code:

Phone #:

Fax #:

Release Records to:

If provider uses eClinical Works please send records via eCW P2P

GOLD PEDIATRICS

15005 Shady Grove Road

Suite 450, Rockville

Maryland 20850

Information to be Released

All Records

X-Ray(s)

Pre Op.

Labs

Growth Charts

Most Recent WCC

Dates of Services

Immunizations

Other

If Other, Please Specify:

Reason for Record Release

Provider Change Moved Insurance Change Other

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 of Patient or Legal Guardian

Name of Patient of Legal Guardian

Date

**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.**

FOR INTERNAL PURPOSES ONLY: NAME & TITLE OF PERSON SUBMITTING REQUEST FOR RECORDS:

FAXED

EMAILED

MAILED

TO:

ON:

Your information will be encrypted.