Arbor Medical Records Release Over 18

REQUEST FOR RELEASE OF MEDICAL RECORDS (over 18)
Patient's Name*
Date of Birth*

MonthDayYear
Please release:

All Records (including growth charts and immunization records)Labs/RadiologyImmunization RecordsDischarge SummaryOther
Please release medical information FROM:
Name and location of office records are coming from
Please release medical information TO:
Arbor Pediatrics 1130 N Kimball Ave, Ste 100 Southlake, TX 76092 t 817-865-3564 f 817-865-3576
I hereby authorize the above mentioned provider to release and/or disclose the medical information as requested above to Arbor Pediatrics as I have indicated. I also understand this information may contain information relating to HIV/AIDS or infection with any other communicable diseases, behavioral or mental health services and alcohol and/or drug abuse.
I consent to the release of any HIV/AIDS testing with the rest of my medical records.*

YesNo
Reasons for records release:*

Continuing medical careOther
In understand that I may revoke this authorization in writing at any time. Otherwise, the authorization shall remain valid until such time as it is revoked in writing.
Patient Name*
Signature*

Clear
Today's Date

MonthDayYear
Should be Empty:

REQUEST FOR RELEASE OF MEDICAL RECORDS (over 18)