Request for Release of Medical Records

Please release the medical records for the following children:

Name:________________________Birthdate:_______________

Name of Requesting Parent or Guardian_______________________________

Address of Parent or Guardian______________________________________

_______________________________________

Phone of Parent or Guardian (______)_______________________________

Please release the following Medical records:

(check all that apply)

q Immunization Record, Growth Charts, Problem List, Medication Record and Allergy List

q Copy of the most Recent Physical Exam

q Both of the above plus a copy of the most recent visits up to a total of 20 pages

q All Medical Records

I wish to select the following method for delivery of medical records:

q I will pick up the records in 7 business days

q I wish the records to be sent to my home at the above address.

q Please send the records to the Medical office listed below:

_____________________________________________

q If this box is checked, I do not wish to be called about why I am requesting medical records.

Signed:________________________________________________Date:_____________