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

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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.

Release Records to:

If provider uses eClinical Works please send records via eCW P2P



15005 Shady Grove Road

Suite 450, Rockville

Maryland 20850

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.

**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.