Consent for Release of Medical/Billing Information Patients 18 Years of Age and Older

Johns Creek Pediatrics

Please correct the errors described below.

Patient Name

I understand that I have the option to share or keep my chart and billing records confidential since I am 18 years of age or older and agree with the following:

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OR

I hereby consent to the release of my medical/billing records to the following person(s):

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

You may revoke or change this consent in writing at anytime.

Office Use Only

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