3特典【送料無料+お米+ポイント】 オムロン 自動血圧計 HEM-7250

www.pediatriciansofdallas.com
Joe B. Neely, M.D. • James W. Watkins, M.D. • Matthew Yaeger, M.D. • Somer Curtis, M.D.
Karen R. Halsell M.D. • Chafen Hart, M.D. • Hillary Lewis, M.D.
Robyn M Lilly, CPNP-PC • Amanda Bodwell, CPNP • Ashley London, CPNP-PC/AC
MEDICAL RECORDS RELEASE FORM
This authorization will expire 90 days after the dated signature.
Patient Records coming to Pediatricians of Dallas
By signing this form I authorize you, Pediatricians of Dallas, P.A., to receive confidential protected health
information about my children. Protected health information includes, but is not limited to, progress
notes, immunizations, and wellness exams. The release of any positive or negative test results for AIDS or
HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS will be included with
my children’s protected health information unless otherwise omitted below. The release of any
Psychotherapy Notes will be included with my children’s protected health information unless otherwise
omitted below.
LIST THE PATIENTS FULL NAME and DATE OF BIRTH:
 Patient in office, please fax immunization records ASAP! (214-691-1044)
LIMITATIONS:
 Complete Records
 Do not release HIV/AIDS Test Results/Treatment
 Do not release Drug, Alcohol or Substance abuse records
 Do not release Mental Health Records (including psychotherapy)
 Do not release Genetic Information including test results
 Records of Care from ______________________ to ____________________
PREVIOUS PHYSICIAN INFORMATION: (*Required to obtain medical records.)
*Name:
*Phone:
*Address:
PURPOSE OF THIS MEDICAL RECORDS REQUEST:


*Fax
Patient moving from the area or patient has already moved from area
Patient is changing physicians
ONCE COMPLETE INFORMATION IS OBTAINED, MAIL TO:
Pediatricians of Dallas, PA
Attn: Medical Records
8325 Walnut Hill Ln., Suite 225
Dallas, TX 75231
___________________________________
Name
___________________________________
Signature
Relationship to Patient:
___________________
Date
8325 Walnut Hill Lane, Suite 225 • Dallas, Texas 75231 • 214-691-3535 • fax: 214-691-0404