Authorization Release Of Confidential Medical Information
Pediatrics Healthcare Associates
3701 Eldorado Parkway Suite A
Mckinney, TX 75070
Phone: 972-548-7888 Fax: 972-562-1170
As the guardian of the patient(s) listed below, I give permission to release all medical, mental, and social information to the facility listed. I understand that this information is confidential and will only be used for the benefit of the patient. I further understand that this release is valid for one year from date of signing or until I revoke the authorization in writing.