ROYAL OAK PEDIATRICS, PC

26657 WOODWARD AVENUE, SUITE 200 HUNTINGTON WOODS, MI 48070

248-398-8400

Authorization for Release of Medical Records

PATIENT INFORMATION REQUESTED:
 
  Patient Name:   DOB:  
  Address:   Phone:  
 
I AUTHORIZE ROYAL OAK PEDIATRICS TO: (CHECK ONE):
  Receive Medical Records From:  
  Receive Medical Records To:  
  Receive Medical Records for Personal Use To:  
 
  Name:  
  Address:  
 
OFFICIAL VERIFICATION OF PATIENT REPRESEMTATIVE ID PRIOR TO RECORDS RELEASE: (CHECK ALL THAT APPLY)
  Drivers License  
  Birth Certificate  
  HIPAA Release Form  
  Requestor's Name    
 
TYPES OF RECORDS TO BE RELEASED: (CHECK ONE)
    Our records, including records from previous physicians  
    Specific information only:    
 
INITIAL ON THE LINE BELOW TO SHOW ACKNOWLEDGEMENT OF THE FOLLOWING: (INITIAL PREFERENCE)
 
  I understand that the information above may contain mental health, developmental disabliities, alcoholism, AIDS test results, AIDS-related desease diagnosis, drug abuse or other privileged information.  
 
  I do not wish to disclose information that may contain mental health, developmental disabilities, alcoholism, AIDS test results, AIDS-related disease diagnosis, drug abuse or other privileged information.  
 
REASON FOR REQUEST: (CHECK ONE)
    MOVING-PROVIDE NEW ADDRESS:    
    TRANSFER OF CARE-REASON:    
    OTHER-PLEASE SPECIFY:    
 
  Patient/Parent/Guardian:     Date:    
  Printed Name:     Relationship to Patient: