Release of Medical Records

Release of Medical Records

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name*
Patient 2 Date of Birth*

MonthDayYear
Date
Patient 3 Name*
Patient 3 Date of Birth*

MonthDayYear
Date
Patient 4 Name*
Patient 4 Date of Birth*

MonthDayYear
Date
Patient 5 Name*
Patient 5 Date of Birth*

MonthDayYear
Date
Patient 6 Name*
Patient 6 Date of Birth*

MonthDayYear
Date
I am releasing medical records*

FROM another provider TO Essex PediatricsFROM Essex Pediatrics TO another provider
Reason for transferring:*
Physican Providing Records
Physican Providing Records

Essex Pediatrics
89 Main Street
Essex Junction, VT 05452

Phone: (802) 879-6556
Fax: (802) 872-8021
Releasing Records To
Physician and/or Practice Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Releasing Records To

Essex Pediatrics
89 Main Street
Essex Junction, VT 05452

Phone: (802) 879-6556
Fax: (802) 872-8021
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
I authorize the following to be released via fax/email/mail and understand that there is a $10 charge:*

All records of care between the Start and End dates noted aboveOther
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Should be Empty:

Release of Medical Records

Patients

Physican Providing Records

Physican Providing Records

Releasing Records To

Releasing Records To