Release of Medical Records

I authorize a complete copy of my child’s medical records to be forwarded to:

Whole Care Pediatrics 12337 Jones Rd, Suite 350 Houston Texas 77070

Phone: 281-984-9480 | Fax: 346-314-4976

I authorize Whole Care Pediatrics to receive a copy of my child’s medical records from

Physician/Practice:

Address:

Phone Number:

Fax Number:

Please list each child whose medical record is being requested:

Reason for transfer:

Change of Medical Provider Moving/Relocation Other:

I understand that this authorization is valid one year from today’s date but that I can revoke it in writing at any time.

Signature:

Date:

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