Medical Records Release Authorization

Authorization to Transfer Medical Records

Please complete this authorization for Greater Cleveland Pediatrics to request Medical Records from an outside medical office
Patient's Name*

First NameMiddle NameLast NameSuffix
Patient’s Date of Birth*

MonthDayYear
Date
Age*
By checking the box below, I consent to the release of medical records, for the purpose of transfer of care, for the following time period, from the following medical providers :*

I agree
Date From*

MonthDayYear
Date
Date To*

MonthDayYear
Date
Please list the name and contact information (including phone and fax) of prior medical providers: *
Please include former primary care provider and all other specialists from whom you wish for us to receive records
Parent or Legally Authorized Representative consenting for disclosure of information for patients under 18 years of age (leave blank if patient is over 18 years old)

PrefixFirst NameLast NameSuffix
Relationship to Subject
Type of Medical Information to be disclosed*

All Medical RecordsAmbulatory Clinic RecordsGrowth ChartSub-specialist Consultation RecordsVaccination recordDental RecordsMedical History & Physical ExamsProgress NotesEmergency RecordsImaging ReportsDischarge RecordsLaboratory & Pathology ReportsOperation ReportsPsychological TestsOther
Other Information allowed to be disclosed

I give consent to the release of my HIV/AIDS testing information if there is anyI give consent to the release of information pertaining to drugs and alcoholI give consent to the release of my genetic information and family background informationI give consent to the release of information pertaining to mental health diagnosis or treatment.
Signature of PARENT or Legally Authorized Representative consenting for disclosure of information for patients UNDER 18years of age - OR - Signature of PATIENT consenting for disclosure of information for patients 18 years of age and OLDER*
Name of Person Signing Form*

PrefixFirst NameLast NameSuffix
Date Signed*

MonthDayYear
Date
Signature of PATIENT consenting for disclosure of information for patients OVER 18 years of age (leave blank if patient is UNDER 18 years old)
Medical Record to be released to:

Greater Cleveland Pediatrics

31100 Pinetree Road, Suite 215

Pepper Pike, OH 44124

Phone: 216-236-5446

Fax: 216-468-5954

email: admin@clepeds.com

Please send records via secure email, if possible.
Date Signed

MonthDayYear
Date
Should be Empty:

Authorization to Transfer Medical Records