Medical Records Requests

1530 Celebration Boulevard, Suite 301, Celebration, Florida 34747

Phone (407) 566-9700 • Fax (877) 534-5105

AUTHORIZATION TO REQUEST OR RELEASE HEALTH INFORMATION
Name of Parent or Guardian Requesting Records:
First and Last
Child 1: Name

First NameLast Name
Child 1 DOB:

MonthDayYear
Date
Child 2: Name

First NameLast Name
Child 2: DOB

MonthDayYear
Date
Child 3: Name

First NameLast Name
Child 3: DOB

MonthDayYear
Date
Child 4: Name

First NameLast Name
Child 4: DOB

MonthDayYear
Date
Hereby authorize Celebration Pediatrics Associates, PA to

Request Records From:
Physician and/or Practice Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
Release Records To:
Physician and/or Practice Name
Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
The following type of medical information: (list dates and test if specifics needed)
Lab Results:
Image Results:
Immunizations:
Entire Medical Record:
Physicals:
By indicating "Entire Record" all medical information, information regarding any sexually transmitted disease, psychiatric treatment, drug and/or alcohol abuse, HIV testing, ARC and.or AIDS information in my records will be released. If you prefer certain medical information not be released, please contact the appropriate office staff.
This information for which I am authorizing disclosure will be used for the following purpose:

ReferralTransfer of CareLegal ReviewRelocationInsuranceOther
This option will expire on:

MonthDayYear
Date
If I fail to specify a date, this authorization will expire within 6 months from the date it was signed. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization in writing, the revocation will not apply to information that has already been released. I understand that information has been disclosed, the recipient may re-disclose it and federal privacy laws may not protect the information.

Signature*
Phone Number of Authorized Representative:
Please enter a valid phone number.
*Fee for copying chart is $1.00 per page up to 25 pages, .50 cents per pager thereafter. Authorization must be signed and payment received before the chart will be copied. Please allow 7-10 working days to copy chart.
Should be Empty:

The following type of medical information: (list dates and test if specifics needed)