Solicitud de Registros Médicos

Authorization to release medical record information

I authorize Childrens Cardiviovascular Medicine to realease my medial record to:

I authorize Childrens Cardiovascular Medicine to release my medical records to:

All medical sources, including any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medial facility, or other health care provider that has provided payment, treatment or services to me or on my behalf

Please release the following documentation:

This authorization,as may be. applicable, extends to any medical records covered by any privilege, including without limitation to psychiatric, psychological and mental and records; records relating to drug treatment and/or substance abuse; records related to sexually transmitted diseases and/or social service notes.

Authorization expires one year after it is. signed: