Records Release

Patient Name(Required)

Date of Birth(Required)

Patient Name

Date of Birth

Release Records To

Parent/Physician/Facility(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax #

Request Records from

Physician/Facility(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax #

Establishing with

Dr.Wyatt

Dr.Beebe

Dr.Grooms

Dr.Boon

Dr.Oum

Please release the following information

All Records

Shot Record

Other (Specify)

Specify Record

This authorization will expire 1 year from today's date unless otherwise stated.

There will be a charge for the release of medical records $1 per page for the first 5 pages and $0.25 for each additional page.

I understand that the information in my child's health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature(Required)

Signature of patient (responsible party, if a minor)

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Date