I, the undersigned, authorize and request the release of all medical records (including confidential and protected/privileged health information) and any items related to my care to:

Muskegon Pediatrics, PLC 888 Terrace St, Suite 101 Muskegon, MI 49440

Fax (231) 638-4072

PLEASE SEND ONLY THE FOLLOWING RECORDS:
* Growth Charts   * Immunizations   * Last PE   * Problem List   * Med List

FOR THE PURPOSE OF CONTINUED CARE, I UNDERSTAND THAT: 
- I may withdraw my authorization at any time by submitting a written request to Muskegon Pediatrics, PLC.
- Authorization may be withdrawn except for the following: to the extent that action has been taken in reliance on this authorization or if the authorization is obtained as a condition of obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy
- I may refuse to sign this authorization. If I refuse to sign this authorization, my treatment, payment, health plan enrollment, or eligibility for benefits will not be affected
- Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient, and no longer protected by this rule
- This authorization will automatically expire in 12 months