Release of Medical Records

Advance Pediatrics PLLC

9836W Yearling Road F-1300

Peoria, AZ 85383 (PH) 623-328-8664 (FAX) 623-328-9432

I hereby authorize:

Advance Pediatrics, PLLC
Rakesh K. Arora, MD, MS.
9836W Yearling Rd. F- 1300
Peoria, AZ 85383

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

Patient Name:

DOB:

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 medical records to:

Physician or Facility Name

Address:

City, State & Zip Code:

I understand that I have a right to receive a copy of this authorization.

Parent or Legal Guardian Signature

Date:

Relationship to Patient:

Office Staff Initials & Date:

Release of Medical Records

Advance Pediatrics PLLC

9836W Yearling Road F-1300

Peoria, AZ 85383 (PH) 623-328-8664 (FAX) 623-328-9432

Release of Medical Records

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