EL PASO PEDIATRIC ASSOCIATES

AUTHORIZATION TO RELEASE MEDICAL RECORDS
Today's Date *

Month Day Year
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Patient Name (2)

First Name Last Name
Date of Birth (2)

Month Day Year
Date
Patient Name (3)

First Name Last Name
Date of Birth (3)

Month Day Year
Date
Patient Name (4)

First Name Last Name
Date of Birth (4)

Month Day Year
Date
I authorize *
Name of Previous Provider, Hospital
Phone Number *
Number of Hospital, Clinic. Imaging Centers, Other
Fax Number
Number of Hospital, Clinic. Imaging Centers, Other
To release the following record(s) *

Complete Medical File Urgent Care Visits Ultrasound Results Vaccine Record Last Consultation Notes X-Ray Results Inpatient Records Discharge Summary MRI/CT Results Emergency Room Records EKG Results Lab Results: Other
to

El Paso Pediatric Associates, P.A.

1160 Saddle Bronc El Paso, TX 79925

Ph: 915.593.2033 Fx: 915.595.3916

It is my intent that information furnished is prohibited for any purpose other than that stated above and the recipient is prohibited from disclosing this information to any other party to whom disclosure is not necessary or required for the purpose stated above.

I understand I may revoke this consent at any time before the information has been released. A copy of this authorization will be accepted as the original.

I release the organization complying with this request of all responsibility for loss of confidentiality by access and/or copies for records released in compliance to this authorization.
Guardian's Name *
Guardian's Signature *

Clear
Relationship to Patient *

Mother Father Sister Brother Grandmother/Grandfather Legal Guardian Other
Patient's Signature (If over 18 years of age)

Clear
Should be Empty: