AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS

PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD

Physician that you want records transferred from:

MD's Full Name or Group Practice Name

Telephone

Address

City / State / Zip

Fax

I hereby authorize the release of information from the medical record of:

Patient Name

Date of Birth

NOTE - PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD

Please release information to: PEDIATRIC CLINIC LLC, Opelika, AL - Fax number (334)749-6166

INFORMATION REQUESTED:

Immunization Record / Growth Chart / Last Well Visit

Medical Summary

Labs / X-Ray

Complete Medical Record

PURPOSE OF DISCLOSURE:

Changing Physicians

Continuing Care

Other

(If Other, please specify)

Informed Consent for Release of Confidential Information.

I understand that I may revoke this consent in writing at any time except to the extent action has been taken. I understand that this consent will expire 90 days after the date of my signature unless otherwise specified. I understand that information used for disclosed pursuant to this authorization may be subject to rediscolusure by the recipient and no longer be protected by Federal Privacy Regulations.

Type Full Name of Patient / Parent / Legal Guardian

Date

Relationship to Patient (if requesting for self, patient must be at least 14 years old)

(If patient is 18 or older, patient must request record himself/herself)

Your information will be encrypted.

AUTHORIZATION FOR REQUEST OF MEDICAL RECORDS

***PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD***

***PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD***

PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD

PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD