Medical Records Release | Columbus Children's Clinic

Instructions: Complete this form to authorize your child's previous physician or facility to release their medical records to our clinic. Submit the form and we will handle the rest.

Authorization Submitted!

We received your Medical Records Release Authorization. We will contact the previous provider to request your child's records.

Questions? Call (706) 322-5526

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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

Authorized By (Parent / Legal Guardian Name) *

Date *

Witnessed By (if applicable)

Contact Email *