Authorization to Release Medical Records

I, (Parent or Guardian Full Name) the parent or guardian of the following children: 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

Hereby authorize CCH Pediatric Clinic, PC to request records * : Physician and/or Practice: Practice Name*Street AddressAddress Line 2CityStateZipArea CodePhone NumberArea CodeFax Number Release Records To: Physician and/or Practice: Practice NameStreet AddressAddress Line 2CityStateZipArea CodePhone NumberArea CodeFax Number

Information to be Disclosed

Please list the dates of the treatment/test you wish to release:Date
If Other is marked, please specify: Reason for Other

Purpose of which information is to be used

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. Contact the Clinic Administrator if you wish to revoke your authorization. Without my written permission to revoke this authorization, it will automatically expire after 6 months from the date of signature or upon satisfaction of the need for disclosure or as specified:specify .

I hereby releaseName of group releasing records from all legal liability that might arise from the release of sensitive information. Any further disclosure of my records other than what is outlined above is prohibited without my specific written authorization, or as otherwise permitted by such regulation. I consider a photocopy of this authorization to be valid as original.

I understand that I may inspect the information to be disclosed as provided in 164.524. Authorization must be signed by the patient or legal guardian of the patient, or other authorized representatives. If the patient is unable to give authorization, or physically sign, please state the reason: Reason

Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected by this rule.

Patient Name/ Person authorized to sign for the patient

First NameLast Name

Relationship to Patient

Date

Signature