Authorization to Release Confidential Medical Information

I hereby request that my medical records be released to:

Facility

Address

City

State

Phone

Fax

My records are being transferred from:

Facility: Pediatric Healthcare Associates, P.A.
Address: 3701 Eldorado Parkway Suite A
City: McKinney
State: TX, 75070
Phone: 972-548-7888 Fax: 972-562-1170

Reason for request of records:

Entire Health History

Test Results

Growth Chart & Immunization Records

As the guardian of the patient named below, I give permission to release all medical, mental, and social information to the facility listed. I understand that this information is confidential and will only be used for the benefit of the patient. I further understand that this release is valid for one year or until I revoke the authorization in writing.

Patient Name:

Patient DOB:

Parent Printed Name:

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.

Parent Signature:

Date:

Your information will be encrypted.

Authorization to Release Confidential Medical Information

I hereby request that my medical records be released to:

My records are being transferred from:

Pediatric HealthCare Associates, P.A.