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AUTHORIZATION FOR RELEASE OFMEDICAL INFORMATION
I have confirmed that my child's insurance is in-network with Maeville Pediatrics or will be self-pay. ** We are currently experiencing delays in the processing of our Medicaid enrollment. Thus we are not currently in-network with Medicaid Health Plan or subplans.
Patient Name(s) and Date(s) of birth (please provide information for all children for whom records are needed from a single facility)
I, blanks, hereby authorize the release of medical information to:

Maeville Pediatrics
2813 Smith Ranch Road
Pearland, TX 77584
phone: 832-582-7146
fax: 832-962-8154

Doctor/Hospital from whom records are being released (this is usually your previous pediatrician’s office or your child’s birth hospital):
Type a label
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Please release the following records:
Signature:
Print Name:
Relationship to Patient:
Date

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

AUTHORIZATION FOR RELEASE OFMEDICAL INFORMATION