RELEASE OF MEDICAL RECORDS

Authorization for Release of Medical Records

Please note, the requested medical records will be uploaded onto the portal and available to download as a PDF.
PATIENT'S NAME*
DOB*
ADDRESS*
APT
CITY*
STATE*
ZIP*
HOME PHONE
I hereby authorize Westside Pediatrics P.C. to release the medical records, including laboratory and radiological studies. All transfer forms will be processed within 10 business days and will not be released until full payment is received.
- $25 1st request of records
- $30 2nd request of records
Doctor’s Name/Medical Facility
Address*

Address

Street Address Line 2

CityState

Zip
Date*

MonthDayYear
Date
Signature*

Clear
*Please be aware that an additional fee will be required if your records are stored in an offsite location
Should be Empty:

Authorization for Release of Medical Records