Please Email Or Fax Completed Form To: Or 703-499-9670

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Each Patient MUST Have a Separate Release Form Please Print Clearly

Today’s Date: ______

Reason for Request: ______

Patient’s Legal Name: ______DOB : ______/______/______MM DD YYYY Patient’s Address: ______

Phone Number: ______ Mother  Father  Self (18+ Years)

 Legal Guardian  Other: ______

I hereby RELEASE and AUTHORIZE ALL Pediatrics to release the medical records of the dependent listed (or self if over the age of 18) including diagnosis, treatment, prognosis and recommendation, as well as other data pertinent to the patient's treatment to the following location listed below. I hereby state that I am the child's parent or legal guardian and have the legal right to make and/or restrict healthcare decisions regarding this child, and that my parental authority has not been terminated or restricted by the courts.

Signature: ______Print Name: ______

FOR RELEASE OF HIV / DRUG / ALCOHOL AND/OR PSYCHIATRIC INFORMATION AN ADDITIONAL SIGNATURE IS REQUIRED BELOW.

Signature: ______Print Name: ______

REQUEST BEING MADE FOR THE FOLLOWING: $ INDICATES CHARGE FOR RECORD Consult notes from other specialists will not be included – You must request those through the specialist.

ELECTRONIC MEDICAL RECORDS – 2010-PRESENT PAPER CHART – 2009-PRESENT PAPER CHART – ENTIRE CHART RECOMMENDED – 10-15 BUSINESS DAYS 2 - 6 WEEKS ONE MONTH OR GREATER EMR - Most Current Physical Note and EMR Medical LAST PHYSICAL ( $ ) ALL PEDIAFORM NOTES ( $ )  Summary (FREE – ON CD)    Immunization Record (FREE – ON CD)  LAST LABS ( $ )  ALL LABS ( $ )  EMR – LABS (FREE – ON CD)  LAST X-RAYS ( $ )  ALL X-RAYS ( $ )  EMR – X-RAYS (FREE – ON CD)  ALL OF THE ABOVE ( $ )  ALL OF ABOVE ( $ )

*Medical Record Fee, per state charge schedule, is $25 retrieval and processing fee, plus $0.50 per page for the first 50 pages and $0.25 for each additional page and the cost of postage.

 MAIL RECORDS TO: PICK UP:  Alexandria  Lorton  Lake Ridge (Postage Fee Will be Assessed) Please Complete All Information Below To Have Records Mailed

Name: ______

Street Address: ______

City: ______State: ______Zip: ______Please email or fax completed form to: [email protected] or 703-499-9670