Medical Records Release Form

MEDICAL RECORDS RELEASE TO OLNEY PEDIATRICS
I authorize and request the release of information contained in the medical records of:
Patient Name*
Date of Birth*

MonthDayYear
Date
Patient Name
Date of Birth

MonthDayYear
Date
Patient Name
Date of Birth

MonthDayYear
Date
Patient Name
Date of Birth

MonthDayYear
Date
DO NOT FAX RECORDS (PLEASE MAIL OR PROTECTED EMAIL)
Records to be released: (select one or both as age(s) of patient(s)*

For children under 5yrs: All records: including newborn hospital care, newborn screen, growth chart, labs, and immunizationsFor children 5yrs or older: last 2 well visits, growth charts, labs, immunizations
The purpose for which the following information is being requested:*
Release to:

Olney Pediatrics
18111 Prince Philip Dr., #311
Olney, MD 20832
301-774-4100
NAME OF OFFICE OR FACILITY RELEASING RECORDS*
Address of office/facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number of office/facility*
Please enter a valid phone number.
Fax number of office/facility
Please enter a valid phone number.
I, the undersigned, understand that I may revoke this authorization at any time, in writing, but the request shall remain valid until revoked or upon the expiration of 60 days, whichever occurs first, except to the extent that the records have already been received. I understand that I am giving permission to release medical information which may include treatment for physical and/or emotional illness, pregnancy, genetic testing, communicable diseases, alcohol or drug abuse treatment, and/or HIV, AIDS or AIDS-related information.
Date*

MonthDayYear
Date
Signature of Parent/Guardian*

Clear
Relationship to child/children*
Printed name of Parent/Guardian*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Should be Empty:

MEDICAL RECORDS RELEASE TO OLNEY PEDIATRICS