Patient's First Name:   Last Name:

Date of Birth (DOB): [Select One] January February March April May June July August September October November December ,  (Month DD, YYYY)

CONSENT FOR RELEASE OF MEDICAL RECORDS

I certify that I am the Patient or Parent or Legal Guardian of the named person above, and I hereby give my permission for Adult & Pediatric Physicians Group to request release of medical records as indicated below. Indicate Yes or No by each item below. Failure to indicate will delay release.

 Specific Information:

Facility's Name:

Doctor's Name: 

Street Address:      Suite Number:

City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NJ NH NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR VI ZIP:

Phone:   Fax:

Signature of Parent/Legal Guardian                                                Date

PLEASE SEND VIA FAX TO EXPEDITE PATIENT CARE                                BY US MAIL

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