Medical Records Release Authorization – San Fernando Pediatrics and Urgent Care

Is the patient ADULT or PEDIATRICS? *

Patient's Full Name *

First

Last

Patient's Date of Birth *

Patient's Phone Number *

Email *

I authorize the release of medical information to: *

Authorization *

I authorize the release of medical information from the medical office(s) listed below to the above clinic. I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization shall remain valid until such time as it is revoked in writing. Purpose of disclosure is for treatment and coordination of care.

How many Doctor's offices or Health Facilities are you getting records from? *

Please list the Doctor's name or the Health Facility's name to obtain medical records from

Doctor or the Health Facility's name: *

Please enter Doctor's name or the Health Facility's name

Doctor's Phone Number *

Doctor's Fax Number (if known)

Second Doctor's Office or Health Facility:

Doctor or the Health Facility's name: *

Please enter Doctor's name or the Health Facility's name

Phone Number *

Fax Number (if known)

Third Doctor's Office or Health Facility:

Doctor or the Health Facility's name: *

Please enter Doctor's name or the Health Facility's name

Phone Number *

Fax Number (if known)

Signature

I authorize the release of medical information from the medical office(s) listed above to the above mentioned clinic. I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization shall remain valid until such time as it is revoked in writing. Purpose of disclosure is for treatment and coordination of care. *

Clear Signature

Signature of patient or legal guardian

Your Name *

First

Last

Your relationship to the patient *