Records Release TO ASP

REQUEST RECORDS TO BE SENT TO ALL-STAR PEDIATRICS
Records to be sent FROM (Doctor/Practice/Hospital Name)*
Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider's Phone Number

Area CodePhone Number
Provider's Fax Number

Area CodePhone Number
Child's Name (Full Name)*
Date of Birth*

MonthDayYear
I authorize the use and disclosure of the children’s medical records listed below to:

                 All-Star Pediatrics

                 4915 E Baseline Rd Ste 119

                 Gilbert AZ 85234

                 Phone 480-832-0480

                 Fax 480-832-0490
The information to be used/disclosed includes the following:*

Entire recordMost recent visit/physicalGrowth chartImmunization recordsLab resultsOther
I understand and authorize that this may include confidential communicable information (ARS § 36-881), confidential HIV-related information (ARS § 36-661), confidential alcohol or drug abuse-related information (42 CFR Sec 2.1 Et Seq), and/or confidential mental health, diagnosis and/or treatment information. I understand that I may revoke this authorization, in writing, at any time. This authorization will expire one year from the date signed.
Parent/Guardian Signature*

Clear
Relationship to the child*

MotherFatherOther
Date

MonthDayYear
Date
Should be Empty: