Medical Records Release Form

Saugatuck Pediatrics LLC

191 Post Road West, Suite 201

Westport, CT 06880

www.saugatuckpeds.com

Phone (203) 793-4747

Fax (877) 809-0848

I, (Parent or Guardian Full Name/Patient if aged 18+ years) the parent or guardian of the following children (or self if aged 18+ years): Child 1: First NameLast Name DOB: Date Child 2: First NameLast Name DOB: Date Child 3: First NameLast Name DOB: Date Child 4: First NameLast Name DOB: Date Child 5: First NameLast Name DOB: Date

The information for which I am authorizing disclosure will be used for the following purpose:

Hereby authorize Saugatuck Pediatrics LLC to:

Request Records FROM: Physician and/or Practice: Street AddressAddress Line 2CityStateZipArea CodePhone NumberArea CodeFax Number

Release Records TO: Physician and/or Practice: Street AddressAddress Line 2CityStateZipArea CodePhone NumberArea CodeFax Number

Release Records to Self:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

By checking this box you agree to receive text messages from Saugatuck Pediatrics, you can reply stop to opt-out anytime.

The following type of medical information should be released, By indicating "Entire Record" all medical information, information regarding any sexually transmitted disease, psychiatric treatment, drug and/or alcohol abuse, HIV testing, ARC and/or AIDS information in my records will be released. If you prefer certain medical information not be released, please contact the office:

We can provide you with one free copy of your medical record on a flashdrive. If you prefer paper records, the fee is $0.65 per page. Authorization must be signed and payment before chart will be copied. Please allow 7-10 working days to copy chart.

This authorization will expire on: Date*
If I fail to specify a date, this authorization will expire in 6 months from he date it was signed.
I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization in writing, the revocation will not apply to information that has already been released.

Signature*Area Code*Phone Number*
Signature/Phone Number of Parent/Guardian (or patient if aged 18+ years)

AUTHORIZATION TO REQUEST OR RELEASE HEALTH INFORMATION