Authorization For Release of Records

Release of Medical Information

This From is Encrypted & HIPAA Compliant
Please mark one of the following:*

I am requesting records to be released from a prior physician to Comfort Care PediatricsI am requesting records to be released from Comfort Care Pediatrics to a medical office/person
Please provide the information of whom we are requesting from or releasing to:
Name (Physician, Clinic, Hospital or parent):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.
Fax:
Please enter a valid phone number.
I hereby authorize the release of the follwoing records:*

Problem ListImmunization RecordGrowth ChartMedication ListReviewed by MDScanned/LoggedOther
Patient(s) Name:
Date of Birth

MonthDayYear
Date
Patient(s) Name:
Date of Birth

MonthDayYear
Date
Patient(s) Name:
Date of Birth

MonthDayYear
Date
Patient(s) Name:
Date of Birth

MonthDayYear
Date
I hereby authorize the release of the above-mentioned medical records and will not hold the releasing party responsible for any legal liability that may arise as a result of the release of this information.
Parent or Legal Guardian

Clear
Date

MonthDayYear
Date
Printed Name of Parent or Legal Guardian
Witness Signature

Clear
Date

MonthDayYear
Date
Printed Name of Witness
Should be Empty:

Release of Medical Information