Medical Records Request

Authorization for the Release of Protected Health Information to Storybook Pediatrics

Storybook Pediatrics *

130 Enterprise Pkwy
McDonough, GA 30253
679-583-9071  678-583-9319(f)

Authorization for the Release of Protected Health Information

Date *

(MM/DD/YYYY)

Email to send my copy

Confirm Email to send my copy

Email and email verification

Parent(s) Names/Legal Guardians *

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)

Medical Information Requested

Information Requested *

Complete Medical Records

Vaccine Records & Last Well Check Notes

Other

Medical Practice or Physician for this Request

Name

Phone

Fax

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. *

I request the transfer of this information

Relationship to patient *

Signature *

Clear

Printed Name of Person Signing Above *