Medical Records Release "FROM" Tosa Pediatrics

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:
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone*
Format: (000) 000-0000.
mailed to the address below ($10 fee per patient)in person when called at the number below ($5 fee per patient)
If mailing records, please list the address records should be sent to:
If picking up records, please list the phone number below to call:
Reason for transfer*
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.
Parent/Guardian Name*
Relationship*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical Records Release Form