Medical Records Request | Storybook Pediatrics

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

Email to receive your copy (Optional. NOTE: Gmail will reject delivery of this form.)

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Enter a confirmation email address.

Date *

(MM/DD/YYYY)

Parent(s) Names/Legal Guardians *

For which clinic is this form?

Storybook Pediatrics

G. F. Still ADHD Clinic

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

Signature *

Clear

Printed Name of Person Signing Above *