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