Please print, fill-in and sign this form. Then send it to us for processing.

Authorization to Release Confidential Medical Records

1.      Patient Name:                                                          Date of Birth:                       

2.      Patient Name:                                                          Date of Birth:                       

3.      Patient Name:                                                          Date of Birth:                       

I hereby authorize a copy of my child's medical records to be released FROM:

Name:                                                                        Tel:                                         

Address:                                                                    Fax:                                         

Address continued)                                                                                                    

I hereby authorize a copy of my child's medical records to be released TO:

Indianapolis Independent Pediatricians                                                         Atten.: Dr. Dan Hayford and Dr. Shana Zwick                                               3850 Shore Drive, Suite 315                                                                 Indianapolis, IN 46254-4693                                                                     Tel: 317-293-7177     Fax: 317-293-3991

Records to be released:

�  All available medical records:

�  Specific records (explain):                                                                                       

�  Records NOT to be released:                                                                                 

The purpose or need for this release:                                                                          

Parent/Custodian Name (Print):                                                                                   

Parent/Custodian Signature:                                                          Date:                       

If custodian, relationship to patient:                                                       

A photocopy or facsimile of this authorization shall be as valid as the original.

Note: This information is disclosed from records whose confidentiality is protected by Federal law.  Federal Regulations 42CFR, Part (2) prohibits any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.  This consent may be revoked at any time, except to the extent that action has already been taken.  A general authorization for the release of medical or other information is not sufficient for this purpose.  There may be a fee associated with the copying/mailing of this information.

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