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.
We are excited to announce these providers are accepting new patients! Michael D. Wyatt, M.D., FAAP, Catherine G. Boon, M.D., FAAP, Mary C. Grooms, M.D., FAAP, Tanya E. Banks, APRN, Chris Schreier, APRN,DNP