Authorization to Release Confidential Medical Information

Pediatric HealthCare Associates, P.A.

Please correct the errors described below.

I hereby request that my medical records be released to:

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

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.

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.

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