Medical Records Release Authorization

Medical Records Transfer Authorization Form
I, First Name Last Name , authorize transfer of medical records for the child/children named below:
Child #1 Name: First Name Last Name, DOB: MM/DD/YYYY, My Relationship:

Click here if other children in your family need medical records transferred to us from the same prior medical practice. You can add up to 5 additional children on this form. Or click Next below if you are transferring only one child.
Child #2 Name: First Name Last Name, DOB: , My Relationship:
Child #3 Name: First Name Last Name, DOB: , My Relationship:
Child #4 Name: First Name Last Name, DOB: , My Relationship:
Child #5 Name: First Name Last Name, DOB: , My Relationship:
Child #6 Name: First Name Last Name, DOB: , My Relationship:

Where are you transferring from?

To transfer records from Childhood Health Associates of Salem, simply select the first button beloe. To request records from another practice select the second button and enter the practice name, address and fax number (if known) below
From:

Childhood Health Associates of Salem, 23rd St NE, Salem, OR 97301 Fax: (503) 364-0364Other
TO:

Small Town Pediatrics, LLC 607 Welch St Silverton, OR 97381

Request for Records
The purpose of this request is for:

Continuing care with Dr. Hamblin or Dr Helm in their new locationTransferring care to Small Town Pediatrics in SilvertonOther
For each person listed above, please release the complete medical records, including all chart notes, immunization records, medication treatment history, notes from hospitalizations, specialists and other referral services, etc.
Some records may be subject to special confidentiality laws and regulations. I agree to disclosure and transfer to Small Town Pediatrics each of the following types of medical records for all above named persons:

information on HIV/AIDS status/testing, if aplicableinformation pertaining to drugs and alcohol, if anygenetic testing and family background information, if applicableinformation pertaining to mental health diagnosis or treatment, if any.

By my electronic signature below, I request electronic file transfer of medical records as instructed by Small Town Pediatrics. By law, transfer must be completed within 30 calendar days of receipt.

I understand I may revoke this authorization at any time, but that it remains valid unless/until revoked in writing.
Signature of Parent or Legally Authorized Guardian

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Date Signed

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Address

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Medical Records Transfer Authorization Form