KAP Medical Records Release Request

This is used to request medical records from a former practice, hospital or specialist.

Please correct the errors described below.

Additional Patient

1. I authorize the use/disclosure of the above named individual’s health information as described below: 2. The following below organization is authorized to make the disclosure:

5. This information is being disclosed to and used by: Name: Kid Approved Pediatrics Address: 11875 Coit Rd / Frisco / Texas / 75035 P:972-787-0044 F:214-382-0065 Email: Staff@kidapprovedpediatrics.net (This is email is secure & HIPPA compliant)

6. I understand that I have a right to revoke this authorization at any time. I understand that is I revoke this authorization I must do so in writing and present my written revocation to KAP. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

7. I give permission to release all medical, mental and social information to KAP. I understand that this information is confidential and will only be used by KAP. I further understand that this release is valid for 90 days.

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

This will be used for contact purposes only

Your message will be encrypted and can only be read by Kid Approved Pediatrics.