southfieldpeds.com - Records Release from Outside Provider

Authorization to Obtain Records
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Patient
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I,parent/guardian , as parent, guardian authorize Southfield Pediatrics to obtain medical records from:
Dr.:
Address:
Phone Number:
Please enter a valid phone number.
Fax:
Please mail or fax records to Southfield Pediatrics 31500 Telegraph Road, Ste 105 Bingham Farms, MI 48025 Fax: (248) 540-8701

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 and 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 Obtain Records