Authorization For Release Of Medical Records

Starlight Pediatrics | Dr. Maria Castro | Phone:919-762-5113 | Fax:919-762-5130

Please correct the errors described below.

Add another patient

Authorize the release of information related to AIDS, HIV, psychiatric care and/or psychological assessment and treatment for alcohol/drug abuse


Please mail of fax Medical Records to:


STARLIGHT PEDIATRICS PLLC

500 Holly Springs Road, Suite 101

Holly Springs NC 27540

Phone: (919) 762-5113 Fax: (919) 762-5130


I hereby authorize disclosure of health information for the above name patient. Unless otherwise revoked, this authorization will expire in one (1) year from date signed. I understand that I may revoke this authorization at any time by notifying Starlight Pediatrics in writing, but it will not affect any information released prior to cancellation. I understand that I can refuse to sign this authorization and that my refusal will not affect my child/children’s ability to obtain treatment, or to process payments. I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be redisclosed and would no longer be protected by these regulations.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Your information will be encrypted.

Loading...