• Medical Records Release Form

    Medical Records Release Form

    From Tosa Pediatrics

  • I authorize Tosa Pediatrics to release the records for the following patient(s) for the purpose of transfer:

  • Date of Birth*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     . .
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     . .
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth
     . .
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Select one option*

  • There is a $5 fee per patient for records pickup and a $10 fee per patient for records to be mailed.

    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.

  • Date*
     . .
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: