Patient Authorization for Use and Disclosure of Protected Health Information
If you would like your child's complete medical record to be transferred to Adams Pediatrics, you may fill out this form online, print it, sign it, and bring it to your appointment.(You will need to complete one form for each child.) We will then send your request to your former doctor.
You may also use this form to request records from Adams Pediatrics. Again, fill out this form online, print it, sign it, and bring or send it to Adams Pediatrics. (One form for each child, please.)
Please note that we will release medical records at no charge if they are to be sent directly to another provider. Medical records released to any other person(s) or entitiy will be charged according to the rulings set forth by the Texas State Board of Medical Examiners.
As a courtesy to our patients, we will charge $5.00 for the first 50 pages (pages 1-50) of a medical record, and $0.10 per page for each page after 50.
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