Pediatric Therapy Medical Records Release Form

MEDICAL RECORDS RELEASE FORM

RE:

_____________________

DOB: _____________________

I hereby authorize Main Line Pediatric Therapy Center, Inc. to request patient

information from:

Name: _____________________________________________________

Address: ___________________________________________________

___________________________________________________________

Zip Code

Telephone: _(_____)_____________________________

Information to be released:

____________________________________________________________________

This authorization is subject to my written cancellation at any time.

______________________________________

_________________________

Signature of Parent/Guardian

Date

_______________________________________

_________________________

Witness

Date

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Parent category: Legal