AUTHORIZATION TO RELEASE MEDICAL RECORDS

MEDICAL RECORDS REQUEST FOR

Patient's First Name

Patient's Last Name

Date of Birth:

Name of Doctor or Facility:

Name of the doctor or facility you are requesting medical records from

Address of Doctor or Facility:

Office address of the doctor or facility you are requesting medical records from

Doctor/Facility Phone:

Doctor/Facility Fax:

Reason for Request:

Name of Northside Pediatrics Staff requesting this form

Please send the following information/copies of medical records on: (Mark all that Apply)

Complete Medical Record

Immunization Record

X-Rays

All Labs

I HEREBY REQUEST AND AUTHORIZE THE ABOVE NAMED DOCTOR/TREATMENT FACILITY TO RELEASE ALL MEDICAL INFORMATION REQUESTED FOR THE PURPOSES DESCRIBED TO

Northside Pedatrics Associates
500 Medical Center Blvd, Suite 350, Conroe, TX 77304
Phone: 936 - 270 - 8655 Fax: 936 - 270 - 8739

Signature of Parent/Guardian

Date

Phone Number

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