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: Please SelectParentFoster ParentLegal Guardian
Child #2 Name: First Name Last Name, DOB: , My Relationship: Please SelectParentFoster ParentLegal Guardian
Child #3 Name: First Name Last Name, DOB: , My Relationship: Please SelectParentFoster ParentLegal Guardian
Child #4 Name: First Name Last Name, DOB: , My Relationship: Please SelectParentFoster ParentLegal Guardian
Child #5 Name: First Name Last Name, DOB: , My Relationship: Please SelectParentFoster ParentLegal Guardian
Child #6 Name: First Name Last Name, DOB: , My Relationship: Please SelectParentFoster ParentLegal Guardian
TO:
Small Town Pediatrics, LLC 607 Welch St Silverton, OR 97381
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.
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.