Medical Records Release | Columbus Children's Clinic

Instructions: Fill in all fields, draw your signature in the signature box at the bottom, then click Sign & Print / Save as PDF. Email the completed PDF to childrens1546@gmail.com or fax to (706) 322-1237.

Previous Physician / Facility (Records Coming FROM)

Physician or Facility Name *

Address

Telephone

Fax

Parent / Legal Guardian

I, * (Parent or Legal Guardian Name)

as Parent or Legal Guardian of the Child(ren) indicated below, hereby authorize the above-named physician to release the specified Medical Records through fax or mail.

Records to Release

Select all records to be released:

Immunization Records Physician Encounter Notes Medical Problems List Growth Charts Laboratory Test Results History & Physical All of the above

Other records (please specify):

Child(ren)'s Names

#	Last Name	First Name	Date of Birth
1
2
3
4

Purpose of Release

Please send the above records to the physician named below for the purpose of:

Physician Receiving the Records

Shilpa J. Vernekar, M.D., F.A.A.P.

DBA: Columbus Children's Clinic

Address: 1546 10th Ave Suite A, Columbus, GA 31901

Tel: (706) 322-5526 · Fax: (706) 322-1237

Authorization Expiry

This authorization will expire in:

6 months 12 months

Important Legal Notice

I understand that: a) I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken prior to receiving the revocation; b) my child(ren)'s treatment, payment of services, enrollment or eligibility for benefits may not be conditioned on the signing of this authorization; c) the information described above may be re-disclosed by the recipient and may no longer be protected by the Federal HIPAA privacy regulations; d) the released records may contain alcohol, drug abuse, psychiatric, HIV testing & results or AIDS information; and e) records will be released within 30 days and if I want a copy of these records, I may have them at a reasonable copy or handling fee, as per State of Georgia regulation.

I have read and understand the above legal notice. *

Authorization Signature

Parent / Legal Guardian Name *

Date *

Signature *

Sign above using your mouse, trackpad, or finger (on phones & tablets).

By signing above, I consent to sign this authorization electronically and agree that my electronic signature is the legal equivalent of my handwritten signature (per the federal ESIGN Act and Georgia UETA). *

Witnessed By (if applicable)

Contact Email *

Medical Records Release Authorization