Your Partners In Pediatric & Adolescent Care!
PEDIATRIC PARTNERS, P.A.
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I hereby authorize the release of information from the medical record of:
Date of Birth:
Date of Birth:
Please Release Information To:
Information to be Released:
Immunization Record/Growth Chart/Last Well Visit
Reason for Release of Information:
Change of Physician
Attorney / Legal
Change of Insurance
Please specify your new carrier:
Informed Consent for Release of Confidential Information.
I understand that once I have requested the transfer of records our relationship with Pediatric Partners will be
terminated. Any questions, concerns or need for care will be directed to your new physician.
I understand that I may revoke this consent in writing at any time.
I understand that this consent will expire 90 days after the date of my signature unless otherwise specified.
I understand that there is a fee for copy services rendered.
I understand that this information may include HIV/AIDS, mental health and chemical dependency diagnosis,
treatment, and test results.
I understand that the information released is for the specific purpose stated above.
I understand that my medical records may contain reports only a physician can interpret.
I understand and have been advised that I should contact my physician regarding the entries made in my medical
record to prevent my misunderstanding of the information contained in these entries.
I will not hold Pediatric Partners liable for any misinterpretation of the information in my medical record as a result
of not consulting my physician for the correct interpretation.
Signature of Patient or Legal Representative
Relationship to Patient
Medical Plaza West • 12200 W. 106th Street, Suite 230 • Overland Park, KS 66215
phone: 913-888-4567 • fax: 913-888-1277 • e-mail & web site: