Request For Medical Records Authorization

Previous Physician
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
I authorize and request that the following medical records:

All Records + Behavioral HealthAll RecordsShot RecordBirth Records from Hospital
For the child(ren) listed below be released to:

Direct Message Address:
medicalrecords@direct.etowahpediatrics.com
Etowad Pediatrics ~ 170 Independent Dr ~ Rainbow City, AL 35906
Fax: 256-413-1470

List the names of the children. More spaces will appear as you fill in the spaces provided.
Child's Name
Date of Birth

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
This information about you is protected under federal law, and you have the right to revoke this authorization in writing. Please be advised, however, that any revocation will be effective only to thte extent we have not already taken action in reliance on your authorization. By signing below, you recognize that the protected health information used or dislcosed pursuant to this authorization may be subject to re-disclosure by the recipient of this deisclosure and may no longer be protected under federal law. We will not condition treatment based on your authorization. You may refuse to sign authorization.
Parent/Legal Guardian:
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: