PEDIATRIC CLINIC LLC
Physician where you want Pediatric Clinic to send records TO:
I hereby authorize the release of information from the medical record of:
NOTE- PLEASE SUBMIT A SEPARATE ON-LINE FORM FOR EACH CHILD.
Please release the following information FROM: PEDIATRIC CLINIC LLC, Opelika, AL:
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.
Your information will be encrypted.