Medical Record Release Medical Release Form Patient Information Name * Name First Name First Name Middle Name Middle Name Last Name Last Name Date of Birth * Street Address * Street Address Street Address Street Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Authorization to Obtain Records Authorization to Obtain Records I authorize Pediatric Gastroenterology, Hepatology and Nutrition of Florida, P.A. to obtain from other doctors, hospitals, etc. Name of Provider or Facility Provider or Facility Address Provider or Facility Address Provider or Facility Address Provider or Facility Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Fax Authorization to Release Records Authorization to Release Records I authorize Pediatric Gastroenterology, Hepatology and Nutrition of Florida, P.A. to release information to parents, other doctors, etc. Name of Provider or Facility Provider or Facility Address Provider or Facility Address Provider or Facility Address Provider or Facility Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Fax Records Request Details Purpose of this request * Healthcare Insurance Coverage Transfer of Care Personal OtherOther Records requested * All medical records related to a specific illness or injuryAll medical records related to a specific illness or injury Treatment summary Copy of the entire medical record (as allowed by the law) I understand that: My right to healthcare treatment is not conditioned on this authorization. if the person or facility receiving this information is not a healthcare or medical insurance provider covered by the privacy regulation, the information stated above can be disclosed. There will be a charge for the requested records, Doctors' offices will not be charged for requested records. Please allow 7-10 business days of this request for records to be available for pick-up or delivery. Signature of Patient or Representative * signature keyboard Clear Relationship to Patient (if requester is not the patient) Captcha Submit If you are human, leave this field blank.
