Medical Records Release to Centennial Pediatrics of Spokane
Please complete one medical record release form per patient. Thank you.
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Requesting records FROM:
Spokane Pediatrics, 315 W. 9th Ave., Ste #200, Spokane, WA 99204, p. 509-960-8894 f. 509-290-6820
Providence Pediatrics, 1919 S. Grand, Spokane, WA 99203, p. 509-747-3081
Providence Psychology, 105 W. 8th Ave., 418C, Spokane, WA 99204, p. 509-474-6920
Other
Please send records to:
Centennial Pediatrics of Spokane, 3010 S. Southeast Blvd., Ste A, Spokane, WA 99223., Fax 509-343-3717
If "Other," please include the medical practice information below.
Name of Practice
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number (if known)
Please enter a valid phone number.
Format: (000) 000-0000.
Information to be released::
General Medical Records (last 2 years of treatment) - This includes growth charts, immunizations and progress notes.
Specific Information (if marked, please explain below)
Information requested if "General Medical Records" not selected.
Purpose of release
Transfer of care
Continuity of care
Other
If "Other," please explain below.
Protected or Sensitive Information: I understand that certain information is considered protected or sensitive and cannot be released without specific authorization as required by law. By checking off the box, I authorize the release of the following protected or sensitive information.
Drug/alcohol abuse/treatment
Sexually-transmitted infections
Mental health/treatment
HIV/AIDS information
You have the right to revoke this authorization at any time, provided that you do so in writing to Centennial Pediatrics of Spokane. Unless revoked, this authorization expires in 180 days or on this date:
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Month
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Day
Year
Date
Parent/Guardian/Patient (if over 18 years old) Signature
*
Printed Name Parent/Guardian/Patient (if over 18 years old)
*
First Name
Last Name
Relationship to Patient
Date
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Month
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Day
Year
Date
Minor Patient's Signature, if applicable*
Date
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Month
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Day
Year
Date
*Due to State and Federal laws, minors can consent to treatment for mental health concerns and alcohol/drug treatment at the age of 13, diagnosis/treatment of sexually-transmitted infections at the age of 14 and birth control at any age. Any patient who is 13 years old or older must sign this form.
Submit
Submit
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