Release of Medical Records (18 and Older)
Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patient
Patient 1 Name
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Patient 1 Date of Birth
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Month
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Day
Year
Date
I am releasing medical records
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FROM Essex Pediatrics TO another provider
Physican Providing Records
Physican Providing Records
Essex Pediatrics
89 Main Street
Essex Junction, VT 05452
Phone: (802) 879-6556
Fax: (802) 872-8021
Releasing Records To
Physician and/or Practice Name
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Releasing Records To
Essex Pediatrics
89 Main Street
Essex Junction, VT 05452
Phone: (802) 879-6556
Fax: (802) 872-8021
I authorize the following to be released via fax/mail and understand that there is a $10 charge, which will be collected before the records are released:
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All records of care for the last five years, unless specified under "Other"
Other
Patient Name
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First Name
Last Name
Patient Signature
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Date
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
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