Medical Record Release

Advance Pediatrics PLLC

9836W Yearling Road F-1300
Peoria, AZ 85383 (PH) 623-328-8664 (FAX) 623-328-9432

REQUEST FOR MEDICAL RECORDS RELEASED TO ADVANCE
PEDIATRICS PLLC

    I hereby authorize:

    To release all checked patient pertinent medical records for the following Patient.

    EvaluationsImmunizationsLab Results
    Growth ChartsRadiology ResultsConsult Notes

    I understand this may include information relating to STI (Sexually Transmitted Infections) including AIDS, HIV Infection, Psychiatric Care, and/or treatment for substance abuse including alcohol and or drug addiction.

    Please send/fax medical records to:

    Advance Pediatrics, PLLC
    9836 W Yearling Road Ste # F-1300
    Peoria, AZ 85383.
    Fax- 623-328-9432

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    623-328-8664

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