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11955 DALLAS PKWY, FRISCO | M-F 8-6 SAT 9-12 SUN 3-5
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MEDICAL RECORD RELEASE

Medical Record ReleaseMichael2022-08-08T10:12:16-05:00

"*" indicates required fields

Step 1 of 3 - Patient Information

0%
How many of your children are transferring medical records to Pediatric People?*

CHILD 1

Name*
Date of Birth*
Gender*

CHILD 2

Name*
Date of Birth*
Gender*

CHILD 3

Name*
Date of Birth*
Gender*

CHILD 4

Name*
Date of Birth*
Gender*

CHILD 5

Name*
Date of Birth*
Gender*

CHILD 6

Name*
Date of Birth*
Gender*
Parent or Legal Guardian*
Relationship to Patient*
Address*
How should we notifiy you once we are in receipt of your medical records?*
Medical Record Release Authorization*
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*
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.
Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY
Address of Outbound Provider (get medical records from)*

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