Medical Records Request

Medical Records Request

Authorization for the Release of Protected Health Information to Storybook Pediatrics

Authorization for the Release of Protected Health Information

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Email and email verification
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Medical Information Requested

Information Requested *

Medical Practice or Physician for this Request

Authorization for release to Storybook Pediatics

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. *