By signing below, you agree to authorize the previous provider named above to disclose and release the records obtained for the evauluation and treatment of the patient listed above to APC Pediatrics.
By failing to sign below, you understand that you (parent/guardian) do not want the records to be released and therefore our office may have the right to cancel or postpone your appointment.
APC Pediatrics reserves the right to charge $20 for a hard copy of medical records for the first 20 pages and .25¢ for any page thereafter.
Authorized parents and legal guardians have access to their medical records through our secured patient portal at no cost.
There will be no charge for a records transfer directly to healthcare providers for coordination and/or transfer of medical care.