Medical Record Release Authorization Form

Per Maryland State guidelines, Gateway Pediatrics, LLC has 21 business days to release your medical records.

I authorize the release of copies of medical records and/or other information as noted above. If specifically indicated by me above I understand that this may include information concerning the following: psychiatric/psychotherapy records, mental health records, drug and alcohol treatment information, specific confidential HIV-related information, and/or any general physical condition information.

I authorize this information be released by method selected above. I understand that I may revoke this authorization at any time to the extent that the person who is to make the disclosure has already acted in reliance on this authorization. If not revoked earlier, this consent will remain in effect for thirty (30) days. I understand I have a right to receive a copy of this request.
Signature of Parent/Guardian (or Patient Signature if 18 years or older)*

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Name of Parent/Guardian (or Patient if 18 Years or Older)*

First NameLast Name
Phone Number of Parent/Guardian (or Patient if 18 Years or Older)*
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Relationship to Patient*
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Medical Record Release Authorization