I,   (Parent or Guardian Full Name)   the parent or guardian of the following children: Child 1:   First NameLast Name   DOB:   Date  Child 2:   First NameLast Name   DOB:   Date   Child 3:   First NameLast Name   DOB:   Date   Child 4:   First NameLast Name   DOB:   Date   Child 5:   First NameLast Name   DOB:   Date
Hereby authorize Celebration Pediatrics Associates PA to: Request Records From:   Physician and/or Practice: 1Street AddressAddress Line 2CityStateZipArea CodePhone NumberArea CodeFax Number   Release Records To: Physician and/or Practice:   2Street AddressAddress Line 2CityStateZipArea CodePhone NumberArea CodeFax Number
The following type of medical information (list dates and test if specifics needed):Lab Results:   3   Image Results:   4   Immunizations:   5   Physicals:   6   Entire Medical Record:   7  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:   ReferralRelocationTransfer of CareInsuranceLegal ReviewOther8   This authorization will expire on:   Date   If I fail to specify a date, this authorization will expire in 6 months from he 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 the information has been disclosed, the recipient may re-disclose it and federal privacy laws may not protect the information.SignatureDateSignature of Authorized Representative SignatureArea CodePhone Number   Witness Phone Number of Authorized Representative