Authorization For Medical Records Release

Authorization for Medical Records Release

**This medical records release form must be sent by the patient or

patient’s parent to the previous medical practice where the patient’s

medical records are currently housed. Once this form is sent to that

practice, the previous practice has up to 30 days to release records and

send them to 411 Pediatrics.

I hereby authorize:

Name of PREVIOUS medical practice:

____________________________________________

to release information from the medical records of:

Patient Name: _________________________________________________________

Date of Birth: __________________________________________________________

[ ] Entire Medical Records

[ ] Other: ______________________________________________________________

to be released to:

411 Pediatrics

925 Westbank Drive, Suite 100

Austin, TX 78746

Ph: (512) 327-0411

Fax: (512) 327-5437

_________________________________

______________________________

Patient or Parent Signature

Date

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Parent category: Legal