Records Release "TO" Tosa Pediatrics Form

Medical Records Release Form

This form is to be used to obtain records from another medical office and sent "to" Tosa Pediatrics. One form is needed per child.
Child's Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Records Released From:
Name (i.e. health facility, physician)
Facility Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone #
Format: (000) 000-0000.
Facility Fax #
Format: (000) 000-0000.
Information to be released:

Other
I, the guardian/parent/patient authorize the release of all medical records for the above listed patient in accordance with the specification listed above. I understand that I have a right to inspect and receive a copy of the disclosed material. A photocopy of this consent shall be valid as the original.
Signature
Relationship to Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: