Medical Records Release Form Name of Parent or Guardian* First Last Check One*Release InformationObtain records fromDiscuss withPatient 1 First Last Patient 1 Date of Birth Date Format: MM slash DD slash YYYY Patient 2 First Last Patient 2 Date of Birth Date Format: MM slash DD slash YYYY Patient 3 First Last Patient 3 Date of Birth Date Format: MM slash DD slash YYYY Patient 4 First Last Patient 4 Date of Birth Date Format: MM slash DD slash YYYY I, (Parent or Guardian), hereby authorize Cincinnati Children's and its agents to (Check One) regarding (Patients).*I consentI do not consentFacility NameWhere you would like records sent to.Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneFaxRelease of information from this health record is for the purpose of:MovingInsurance ChangeSwitch to Adult MDCloser PediatricianUnhappy with careOnly pertinent information is to be obtained/forwarded/discussed and should include: Cincinnati Children's record summary (no charge)(Includes: Immunizations, Last well check, Growth charts, Medications) Complete copies of records ($3.18 per page for pages 1-10, $0.66 for 11-50 and $0.27 for each additional page in accordance with Ohio State Med. Assoc. recommendations) Other SPECIAL AUTHORIZATION FOR RELEASE OF RECORDS FOR MENTAL HEALTH/REHABILITATION, ALCOHOL OR DRUG ABUSE AND OR DEPENDENCY, HIV ANTIBODY TESTS RESULTS AND/OR AIDS DIAGNOSIS AND TREATMENT.Please check all that apply, if the information is to be released. Include information related to diagnosis and/or treatment for alcoholism and/or drug abuse or dependency Include information related to diagnosis and/or treatment for mental health/rehabilitation Include information related to HIV antibody test results and/or AIDS diagnosis and treatment I hereby release you, your physicians, and your employees from any and all liability for fulfilling the authorization request for release of medical information. I understand that this consent is revocable by me, in writing, at any time except to the extent that action has been taken in reliance on it. I also understand that this consent will expire either ninety (90) days after the date of this signature or automatically when the records/information requested on this form has been provided to the requestor.* I agreeElectronic Signature of Patient or Patient Representative* First Last Date* Date Format: MM slash DD slash YYYY Electronic Signature of Witness* First Last Date* Date Format: MM slash DD slash YYYY PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from the records whose confidentiality is protected by law. Any further disclosure is strictly prohibited.CAPTCHANameThis field is for validation purposes and should be left unchanged.