Pediatric Medical Records Release Authorization Form
Use this form to request release of a child's medical records and provide the required patient, guardian, recipient, and authorization details.
Patient and Guardian Information
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian/Requestor's Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Parent
Legal Guardian
Grandparent
Foster Parent
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Release Authorization Details
Recipient Name or Organization
*
Recipient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Recipient Email
example@example.com
Specific Records Requested
*
Records Date Range - From
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Records Date Range - To
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization Timing and Confirmation
Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration Date or Event
*
Confirmation
*
I understand the release request and confirm the information provided is accurate
Submit Authorization Request
Should be Empty: