Authorization to Release Confidential Medical Information

I hereby request that

Date of Birth

medical records be released to:

Pediatric Healthcare Associates, P.A.
3701 Eldorado Parkway, Ste. A McKinney, TX 75070
Phone: 972-548-7888 Fax: 972-562-1170

My records are being transferred from:

Facility or Provider Name:

Street Address:

City:

State:

Zip-code:

Phone:

Fax:

Reason for request of records:

Transferring Providers

Specialist Consultation

Personal Use

Please Release:

Entire Chart/Health History

Test Results

Growth Chart & Immunization Records

Other:

As the guardian of the patient named below, I give permission to release all medical, mental, and social information to the facility listed. All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, telephone messages, and records received by other medical providers. All laboratory records, radiology and diagnostic reports. 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.

Parent Printed Name:

Parent Signature:

Date:

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