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Medical Records Release Form

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Medical Records Release Form

Celebration Pediatrics Medical Release Form

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Please complete this form to authorize the release of your medical records.

Email*

Patient Name*

Date of Birth*

Address*

Phone Number*

Fax Number

Email Address

Date of Request*

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Description:Easily share your medical records with Celebration Pediatrics using our Medical Records Release Form. This form ensures that your medical information is kept confidential and is only shared with authorized individuals.

Are you in need of sharing your medical records with Celebration Pediatrics? Our Medical Records Release Form makes it easy for you to do so. This form is designed to protect your privacy and ensure that your medical information is only shared with authorized individuals. By filling out this form, you can give Celebration Pediatrics permission to access your medical records from other healthcare providers. This can be especially helpful if you are a new patient or if you have recently moved to the area. Our form is easy to use and can be completed quickly. Simply provide your personal information and the information of the healthcare provider you wish to share your records with. You can rest assured that your medical information will be kept confidential and secure.

First Name*

Last Name*

Date of Birth*

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First Name*

Last Name*

Date of Birth*

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Full Name*

Date of Birth*

Address*

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Household Name*

Head of Household Name*

Address*

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Full Name*

Date of Birth*

Gender*

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Patient Name*

Patient ID*

Encounter Date*

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Date of Birth*

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Gender*

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First Name*

Last Name*

Phone Number*

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