Medical Release Form printable pdf download

Medical Release Form

First Name_________________ Last Name______________ MI____

Date of Birth___________ This form will authorize you to release my child’s

medical information to Lancaster Pediatrics.

I, hereby authorize disclosure of my protected health information as

follows: (check all that apply)

_ Complete medical records for all services to include: History and

physical exam, Progress notes, Lab or X-ray reports, Inpatient Admissions,

Physical Therapy

_ Athletic Injury Status

_ Records related to the following date(s) of service

__________________________________________

Name of Provider or Practice Name who is to release information:

Name _____________________________________________

Address____________________________________________

Phone______________________ Fax____________________

The purpose of this release of information is for:

_Transfer of record to another provider

_ Attorney

_ Personal Use

_ Other (Describe) ____________________________

_________________________

_______________________

Signature of Parent or Guardian

Date

_________________________

_______________________

Signature of Witness

Date

Medical Release Form