Muskegon Pediatrics Records Release

Authorization to Release Medical Information
Name of Patient*

First NameLast Name
Date of Birth*

MonthDayYear
Primary Contact Number*
Please enter a valid phone number.
Release Records FROM:*

Shoreline PediatricsMuskegon Family CareHackley Community CarePort City PediatricsOther (complete Location field)
Practice Name/Address*
Enter the practice's name and complete address

I, the undersigned, authorize and request the release of all medical records (including confidential and protected/privileged health information) and any items related to my care to:

Muskegon Pediatrics, PLC
888 Terrace St, Suite 101
Muskegon, MI 49440

Fax (231) 638-4072

PLEASE SEND ONLY THE FOLLOWING RECORDS:
* Growth Charts * Immunizations * Last PE * Problem List * Med List

FOR THE PURPOSE OF CONTINUED CARE, I UNDERSTAND THAT:
- I may withdraw my authorization at any time by submitting a written request to Muskegon Pediatrics, PLC.
- Authorization may be withdrawn except for the following: to the extent that action has been taken in reliance on this authorization or if the authorization is obtained as a condition of obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy
- I may refuse to sign this authorization. If I refuse to sign this authorization, my treatment, payment, health plan enrollment, or eligibility for benefits will not be affected
- Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient, and no longer protected by this rule
- This authorization will automatically expire in 12 months

Signature of Legally Responsible Party*

Clear
Relationship to Patient*
Patients 11yr+ Must Also Sign

Clear
Shoreline Pediatrics Address
Shoreline Pediatrics, PLC 684 Harvey St #201 Muskegon, MI 49442 Fax (231) 773-8979
Muskegon Family Care Address
Muskegon Family Care 2201 S Getty St Muskegon, MI 49444 Fax (231) 733-9711
Hackley Community Care Address
Hackley Community Care 2700 Baker St # 3A Muskegon, MI 49444 Fax 231.737.0534
Port City Pediatrics Address
Port City Pediatrics PLC 1455 Farr Rd Norton Shores, MI 49444 Fax 231-739-8502
Should be Empty:

Authorization to Release Medical Information