Medical Release Record Request

1
Are we Transferring or Requesting medical records?* This field is required.¿Estamos transfiriendo o solicitando registros médicos?
Requesting medical records (Solicitud de registros médicos)
Transferring to another doctor (Transferir a otro doctor)
New Patient requesting medical records
2
Reason for records request?* This field is required.Motivo de la solicitud de registros?
Changing physicians (Cambiando médicos)
Medical procedure pending (Procedimiento médico pendiente)
Personal use (Uso personal)
Other
3
How many of your children are you transferring or requesting medical records only?A cuántos de sus hijos está transfiriendo o solicitando registros médicos únicamente?
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2
3
4
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Child's Name (1)* This field is required.Nombre del niño (1)
First Name
Last Name
5
Child's Date of Birth (1)* This field is required.Fecha de nacimiento del niño (1)
Date
Year
Month
Day
6
Child's Name (2)Nombre del niño (2)
First Name
Last Name
7
Child's Date of Birth (2)Fecha de nacimiento del niño (2)
Date
Year
Month
Day
8
Child's Date of Birth (3)Fecha de nacimiento del niño (3)
Date
Year
Month
Day
9
Child's Name (3)Nombre del niño (1)
First Name
Last Name
10
Child's Name (4)Nombre del niño (1)
First Name
Last Name
11
Child's Date of Birth (4)Fecha de nacimiento del niño (4)
Date
Year
Month
Day
12
Timeframe/period of records being requested? (If not provided - all records will be released)* This field is required.¿Plazo / período de registros solicitados? (Si no se proporciona, se liberarán todos los registros)
13
Physician's Name (Medical Group Name)* This field is required.Nombre del médico (nombre del grupo médico)
First Name
Last Name
14
If Transferring please provide Physician/Medical Group AddressDirección
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Fax Number (Only if Transferring)Número de fax (SOLO si se transfiere)
Area Code
Phone Number
16
Phone number (Only if Transferring) Número de teléfono (solo si se transfiere)
Area Code
Phone Number
17
Records Requesting (Choose all that apply)* This field is required.Solicitud de registros (Elija todos los que apliquen)
Immunization Records (Registros de inmunización)
Insurance Information (Información del seguro)
Labs/Xrays (Laboratorio/Radiografía)
Physical Form (Forma física)
All records (Todos los registros)
18
Disclosure Consent* This field is required.Consentimiento de divulgación
I understand that the records being requested are confidential and cannot be disclosed without my (the patient and/or legal guardian) authorization, written and/or otherwise permitted by law. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected.
Entiendo que los registros solicitados son confidenciales y no pueden divulgarse sin mi autorización (del paciente y / o tutor legal), escrita y / o permitida por la ley. La información utilizada o divulgada de conformidad con esta autorización puede estar sujeta a una nueva divulgación por parte del destinatario y ya no está protegida.
19
Consent for information to be released* This field is required.Consentimiento para la publicación de información
I understand that the specified information to be released may include but is not limited to history, diagnoses, and/or treatment of drug and alcohol abuse, mental illness, or communicable disease, including HIV and/or AIDS.
Entiendo que la información especificada que se divulgará puede incluir, entre otros, historial, diagnósticos y / o tratamiento del abuso de drogas y alcohol, enfermedades mentales o enfermedades contagiosas, incluido el HIV y / o el AIDS.
20
Authorization/Time Frame of Consent* This field is required.Autorización / Marco de tiempo de consentimiento
I understand that I may revoke this authorization in writing at anytime except to the extent that action has been taken in reliance upon the authorization. The authorization is valid only for the reason requested a new request must be filled out for additional reasons/request.
Entiendo que puedo revocar esta autorización por escrito en cualquier momento, excepto en la medida en que se hayan tomado medidas en función de la autorización. La autorización es válida solo por el motivo solicitado, debe completarse una nueva solicitud por razones / solicitud adicional.
21
Parent/Guardian Name* This field is required.Nombre del padre / tutor
First Name
Last Name
22
Parent/Guardian Address * This field is required.Dirección del padre / tutor Nombre del padre / tutor
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
23
Parent/Guardian Phone Number* This field is required.Número de teléfono de padre / tutor
Area Code
Phone Number
24
Parent/Guardian Email* This field is required.
example@example.com
Confirm Email
25
Parent/Guardian Signature* This field is required.Firma del Padre / Tutor
Clear
26
Please attach picture ID - ONLY THE RESPONSIBLE PARTY ON FILE CAN REQUEST AND RELEASE MEDICAL RECORDS* This field is required.Adjunte una identificación con foto: SÓLO LA PARTE RESPONSABLE EN EL ARCHIVO PUEDE SOLICITAR Y ENTREGAR REGISTROS MÉDICOS.
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Date and Time of Request/Submission
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Pediatric and Adolescents Center of Grand prairie and Arlington TX

Address: 2715 Osler Dr Grand Prairie Tx 75051

Phone Number:972-206-2940

FAX NUMBER: 972-602-7261

Text 972-210-0452
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