To Whom it may concern,
I request that a copy of my child's medical records (immunization record, growth chart, recent lab work, specialist reports, and the most recent physical exam) be release and mailed to:
Healthy Kids Pediatrics
211 Main Street
Port Washington, New York 11050
Phone: 516 944-8555
As the pson signing this authorization, I understand that I am giving my permission to the above-named health care entity for disclosure of confidential health records. I understand that information disclosed under this authorizatin might be redisclosed by the recipient and this redisclosure may no londer be protected by federal or state law. I also understand that I have the right to revoke this authorization at any time, but that my revocation is not effective until delivered in writing to the person who is in possession of my health records and is not effective as to health records already disclosed under this authorization.