Medical Records Request | Storybook Pediatrics

Authorization for the Release of Protected Health Information (Select Appropriate Clinic)

For which clinic is this form?

Storybook Pediatrics

G. F. Still ADHD Clinic

Email to receive your copy (Optional)

Confirm Email to receive your copy (Optional)

Enter a confirmation email address.

Date *

(MM/DD/YYYY)

Parent(s) Names/Legal Guardians *

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

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
679-583-9071  678-583-9319(f)

Signature *

Clear

Printed Name of Person Signing Above *