Medical Records Release Authorization

I authorize (please enter name below) Fax: (please enter fax number below) to release the complete history and/or records in your possession concerning any treatment and services rendered. I hereby authorize the release of medical records to Johns Creek Pediatrics, PC.

I authorize Johns Creek Pediatrics, PC to release requested medical records to (Insert Recipient Below) Fax: (Insert Fax Number Below)

I authorize Johns Creek Pediatrics, PC to release requested medical records to (Insert Recipient Below) Fax: (Insert Fax Number Below)

Information Requested:

Fees for additional records charged according to STATE OF GA (1-20 PAGES) $0.97 per page; (21-100) $0.83 per page; (OVER 100) $0.66 per page

Please note our policy for release of records:

• Arrangements must be made for any account balances and printing charges
• Due to personal privacy we require you to pick up the records when ready

By signing this authorization, I authorize the use and disclosure of my child’s protected health information as requested. I understand that this information may be re-disclosed by the recipient and may no longer be protected by the federal HIPPA privacy rule. I have the right to revoke this authorization in writing except to the extent that Johns Creek Pediatrics has already released the requested information. I understand that the medical records released to John’s Creek Pediatrics from another provider will become a permanent part of the patient’s medical records.

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