Medical Records Request

Medical Records Request

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

Enter a confirmation email address.
(MM/DD/YYYY)
For which clinic is this form?

Medical Information Requested

Medical Practice or Physician for this Request

Patient(s)

(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)

Authorization for Release of Medical Record

Information Requested *
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. *