Medical Records Release Form Page 2
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1
2I authorize Lexington Pediatrics, PC to disclose the protected health information described below.
I authorize the release of my complete health record (including records relating to mental
healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
OR
I authorize the release of my complete health record with the exception of the following information:
Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Pregnancy/Sexual Activity
Other (please specify): _______________________________________________
PLEASE COMPLETE THE INFORMATION BELOW WITH THE NAME, ADDRESS AND PHONE NUMBER OF
THE PERSON TO RECEIVE THE MEDICAL RECORD.
o For continuity of care, our preference is to release your records directly to your new
health care provider. You may also pick up a copy of your record or have us mail it
home.
NAME __________________________________________ TELEPHONE___________________________
ADDRESS _____________________________________________________________________________
□ Either I or the above named person will pick up my record
□ Mail record to above address
Patient Signature: ____________________________________
Date:________________
Medi cal Record Release Form 18 up
6/2015
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Parent category: Legal