Rainbow Pediatrics Record Release

Medical Records Authorization For Disclosure Of Health Information:
Patient's Full Name:______________________________ Birth Date:________________________________
Street Address:_______________________ City:_________________ State:___________ Zip:__

Authorizes Release of Records FROM:
_______________________________________________________________________________________
Physician Name/Health Care Facility
_______________________________________________________________________________________
Street Address
_______________________________________________________________________________________
City, State, Zip

Records to be Released TO:

RAINBOW PEDIATRICS, P.A.
110-A Chadwick Square Court
Hendersonville, NC 28739

Information to be Released:
____ Complete Office Records ____ Laboratory Reports
____ Immunization Records ____ Radiology Reports
____ Hospitalization Reports ____ Other (Please Specify Below)
__________________________________________________________________

In compliance with state statutes which require special permission to release otherwise privileged information, please release records pertaining to:
____ Mental health ____ AIDS test results ____ Drug abuse
____ Developmental disabilities ____ AIDS related disease ____ Other diagnosis
Purpose or need for disclosure:
____ Continuation of treatment ____ Legal investigation
____ Insurance purposes ____ Other (please specify) ______________

I understand that this authorization shall be valid for 90 days from the date of signature.
I authorize release of my child's medical in accordance with the specifications listed above. I understand written notice is necessary to cancel this request.

Signature of Parent/Guardian:________________________ Date:____________
Legal Authority Is: ____ Parent of Minor ____ Legal guardian ____ Other
Specify Other:________________________________________________________