Authorization to Release Medical Record Information

Pediatric Healthcare Associates

Altoona Office 615 6th Avenue, Altoona, PA 16602
Phone: (814) 944-7383 · Fax: (814) 944-7608

Roaring Spring Office 7664 Woodbury Pike, Roaring Spring, PA 16673
Phone: (814) 224-2555 · Fax: (814) 944-7608

PATIENT NAME

MALE / FEMALE

DATE OF BIRTH

I Authorize:

Name of Physician, Practice, or Facility

Street Address

City, State, Zip Code

Phone/fax number

To Release To:

Name of Physician, Practice, or Facility

Street Address

City, State, Zip Code

Phone/fax number

Please briefly indicate why you would like these records released:

Change of insurance Relocate/continuity of care Other (please explain)

Information to Be Released:

All records Immunization record only Consultation

Progress Note Diagnostic Reports Other

Special Authorization: (check all applicable)

Alcohol and/or drug abuse record Psychiatric records

Sexually Transmitted Disease HIV/AIDS information

Parent/Guardian Signature

Patient Signature (if over 18 years)

Patient Signature (if over 18)

Date

Parent or Guardian Signature

Date

Staff Signature

Date

Phone number

RECORDS FEE:

PICK UP $5.00 per patient MAILED $5.00 per patient plus postage

Pediatric Healthcare Associates · Altoona & Roaring Spring, PA · phcaaltoona.com Authorization to Release Medical Record Information