Authorization for Release of Medical Information

I,__________________________________________, parent or legal guardian of:

Child Name:_________________________________ Date of Birth:____________

Child Name:_________________________________ Date of Birth:____________

Child Name:_________________________________ Date of Birth:____________

Child Name:_________________________________ Date of Birth:____________

hereby consent to the disclosure and release of medical records pertaining to:___________
FROM: Pediatrics by the Sea
Bradley J. Bradford, M.D.
285 SE 5th Avenue
Delray Beach, FL 33483
Ph: 561.272.8991
Fax: 561.272.8985

TO: __________________________________

Phone:__________________

Fax:____________________

The question of privacy between the physicians at the sending facility and my child(ren) is(are) waived. I fully understand that my child(ren)’s medical record or information maintained in connection with the date(s) of service may contain mental health, alcohol, and drug abuse, Human Immunodeficiency Virus (HIV) test results or Acquired Immunodeficiency Syndrome (AIDS) information. The medical records or information authorized to be disclosed by this release are privileged and confidential and may be disclosed only on my, or another legal guardian’s authorization, except as required by law. Only such information believed to be necessary for the purpose expressed shall be released and disclosed. I may inspect and arrange for photocopies of the records that are disclosed. If another legal guardian, or I, refuses to sign this authorization, my child(ren)’s records will not be released.
This authorization is valid for one year from the signed date. I may revoke this authorization at any time (except to the extent that action has already been taken in good faith reliance on this authorization) by submitting a written revocation request to the releasing agency.
I understand that I am responsible for any charges incurred for the copying and production of these records. These include a charge of $1 per page for an amount of pages less than 25 pages, and 25 cents per page for any page over 25 pages. If the chart is in a storage location, I will be charged a $25 fee for retrieval of the chart from storage.

Parent/Guardian Signature__________________________________ Relationship:____________

Printed name:___________________________________________________ Date:____________

Witness’s Signature: _____________________________________________ Date:____________