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
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