Medical Records Request Medical Records Request Authorization for the Release of Protected Health Information (Select Appropriate Clinic) For which clinic is this form? * logo required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key keyalt_solid keyalt keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms highrise mailchimp feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label authorize activecampaign aweber campaignmonitor constant_contact getresponse googlesheets building hubspot icontact mailpoet paypal icon sendinblue sendy salesforce salesforcealt stripe stripealt twilio woocommerce wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Zapier Preview 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 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 * If you are human, leave this field blank. Submit