Medical Records Request Medical Records Request Authorization for the Release of Protected Health Information (Select Appropriate Clinic) Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.) Confirm Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.) Enter a confirmation email address. Date * (MM/DD/YYYY) Parent(s) Names/Legal Guardians * For which clinic is this form? * Storybook Pediatrics G. F. Still ADHD Clinic Medical Information Requested Medical Practice or Physician for this Request Name Phone Fax Patient(s) 1. Child's Name * 1. DOB * (MM/DD/YYYY) 2. Child's Name 2. DOB (MM/DD/YYYY) 3. Child's Name 3. DOB (MM/DD/YYYY) 4. Child's Name 4. DOB (MM/DD/YYYY) 5. Child's Name 5. DOB (MM/DD/YYYY) 6. Child's Name 6. DOB (MM/DD/YYYY) Authorization for Release of Medical Record Information Requested * Complete Medical Records Vaccine Records & Last Well Check Notes Other Other I certify that I am the parent or legal guardian of the above-referenced child/patient and have legal rights to request and authorize the release of the medical records. I am hereby authorizing Storybook Pediatrics, their employees and affiliates, to obtain and review these records. This authorization will expire on the patient’s 18th birthday. * I request the transfer of this information Relationship to patient(s) * Where To Send Records * 130 Enterprise Pkwy McDonough, GA 30253 678-583-9071 678-583-9319(f) Signature * signature keyboard Clear Printed Name of Person Signing Above * Submit If you are human, leave this field blank.
