Valencia Pediatric Associates 27867 Smyth Drive, Suite 100 Valencia, CA 91355 Ph
This authorization allows the healthcare provider(s) named below to release confidential medical information and records. Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/substance abuse have special rules that require specific authorization
Add new row
To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by means of mail, fax, or other electronic methods.
To:
Valencia Pediatric Associates27867 Smyth Drive #100Valencia, CA 91355661-294-8399 Fax
I also consent to the specific release of the following records: (From physician only requests).
Add Patient:
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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: