grahampediatrics.com-Medical Records English

GRAHAM PEDIATRICS OF WOODSTOCK
105 Mirramont Lake Drive, Woodstock GA 30189
Phone: 770-485-9670, Fax: 866-698-9350,www.grahampediatrics.com

Medical Records Request Form

This form authorizes us to release medical records to the person/entity you specify below

Fill out which ONE applies to you below (request or release)

Release Information TO:
Name of Provider/Clinic/Org.
Phone Number

Area CodePhone Number
Fax Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for the request:

Personal UseSchoolLegal PurposesInsurance purposesSpecialists/ReferralTransferring careOther
Request information FROM:
Name of Provider/Clinic/Org.
Phone Number

Area CodePhone Number
Fax Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information to be released

Immunization recordsSchool excusesAll recordsLaboratory Records
I understand that by signing below, I release Graham Pediatrics of Woodstock, LLC. and its employees, agents, officers, and affiliates from any and all liability, responsibilities, claims, and damage which may result from the release of information authorized by this Authorization to Release/Request Medical Records. My child’s health care information can be disclosed as I have authorized and re-disclosed by the recipient and is no longer protected by Graham Pediatrics of Woodstock. I understand that I may revoke this authorization at any time. If not revoked earlier, this consent will remain in effect for one (1) year.
Parent/Legal Guardian Name & Signature

Clear
Relationship to Patient
Date

MonthDayYear
Should be Empty: