Address: 11955 Dallas Parkway Suite 400, Frisco, Texas, 75033, US
Telephone: 214-396-5200

Parent or Legal Guardian*
First Last
Relationship to Patient*
- Mother
- Father
- Legal Guardian
Address*
Street Address City State ZIP Code
Phone*
Email*
How should we notifiy you once we are in receipt of your medical records?*
- Mail
- Telephone
- Email
- Text Message (SMS)
Medical Record Release Authorization*
I authorize this medical record release.
I hereby authorize the Outbound Medical Provider to release my child(ren’s) medical records to the Inbound Medical Provider listed on this form.
Disclosure of Protected Health Information*
I agree to the Protected Health Information Policy.
Expiration Date of Authorization
There is no expiration of this authorization. However, this authorization can be terminated at any time at the written request of the patient.

Right to Terminate or Revoke Authorization
You may revoke this authorization by submitting a written revocation to Pediatric People’s Director of Administration.

Potential for Subsequent Disclosure
Information that is disclosed under this authorization may be disclosed again by the person or organization to which it was sent. The privacy of this information may not be protected under the federal privacy regulation.
Signature of Parent or Legal Guardian*
Date of Signature*
Date Format: MM slash DD slash YYYY

Name of Outbound Provider (from)*
Address of Outbound Provider (get medical records from)*
Street Address City State ZIP Code
Phone of Outbound Provider*
Fax of Outbound Provider*
Inbound Provider Information (send medical records to)*
Pediatric People, PLLC Audra R. Linck, MD, FAAP 11955 Dallas Parkway, Suite 400 Frisco, TX 75033 214.396.5200 - Main 214.504.1796 - Fax Securely upload medical records to us for FREE at: PediatricPeople.com/upload

CHILD 1

CHILD 2