REQUEST FOR MEDICAL RECORDS

REQUEST FOR MEDICAL RECORDS
Name of Person Requesting Records
First and Last
Relationship to Patient(s)
Ex: Mother, Father
Contact Phone #
Format: (000) 000-0000.
Patient's Name
First and Last
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
(If you have more than 1 child please list their names below)
Patient's Name
First and Last
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Name
First and Last
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Name
First and Last
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I, hereby authorize All About Kids Pediatrics, LLC
Name of Previous OR New Practice
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Reason for release of records:

Other
Information to be released:

Other
I hereby authorize the release of medical records for the patient(s) above. This authorization will expire 1 year from the date of signature below. I understand that I may revoke this authorization by submitting written notice of revocation to All About Kids Pediatrics, LLC
Signature of Parent/Guardian or Patient (if 18 years or older)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearToday's Date
Should be Empty: