southfieldpeds.com - Peds Records Release

Authorization to Release Records
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I, parent/guardian , as parent, guardian authorize Southfield Pediatrics to parent/guardian release medical records to:
Dr.:
Address:

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Dates of the records to be released:
Reason for Request:

moving out of areadissatisfied with practicechange of insurancecontinued care with specialistOther
I authorize release of the entire medical record including drug, chemical dependency, alcohol abuse, mental health, communicable disease including sexually transmitted disease and any and all other records in accordance with Federal Regulations.
I expressly authorize information concerning the following serious communicable diseases to be released:

HIV
AIDS-Related Complex (ARC)
Acquired Immunodeficiency Syndrome (AIDS)
Parent/Guardian/Patient Signature

Clear
Date

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This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulation(42 CFR Part 2 and Public Act 258) prohibit from making further disclosure of it without the specific written consent of the person to whom it pertains, or otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. This authorization is valid for one year from the date of request unless otherwise revoked in writing to Southfield Pediatric Physicians.
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Authorization to Release Records