Authorization for release of Medical Records to Omega Pediatrics

Authorization for release of Medical Records to Omega Pediatrics

FAX: 888-723-2802 | TEL: 470-485-6342
Information Regarding Previous Provider
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I authorize the transfer of the entire medical records including patient visits growth charts, vaccine records, laboratory results and mental health referrals of the child(ren) listed below to:

Omega Pediatrics:

1305 Hembree Road, Suite 203

Roswell, GA

Telephone: 470-485-6342

Fax: 888-723-2802
I hereby authorize the release of my complete medical records, including but not limited to, all clinical notes, laboratory results, imaging studies, vaccination records, and any other pertinent medical information and documentation, to Michael Nwaneri, MD. This authorization includes all past, present, and future records until the expiration of this consent. Please list all of the patients for whom you would like medical records to be transferred for:
Parent/Guardian's Name

First NameLast Name
Parent's Email
example@example.com
Parent/Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Please enter the day this form was filled (expires after 365 days)

MonthDayYear
Date
Hour MinutesAM/PM Option
Parent/Guardian's Signature
https://www.omegapediatrics.com
Should be Empty:

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