Request Medical Records from Every Child Pediatrics

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Authorized parents and legal guardians have the right to review or request a copy of their child’s medical records.

How to request a copy of medical records

A Release of Information form needs to be completed. Print, complete and sign the form below.

Release of Information Form

The form can be faxed or dropped off at the clinic. The records are released and delivered in the method selected on the authorization form. We can release and deliver records through mail, verbal, encrypted email, fax or in person.

Please bring a photo ID if you choose to pick medical records up in person.

Special Considerations

• Personal representatives will not be provided access to a minor’s records if the minor was legally able to consent to treatment unless the minor authorize access to this information.
• We may deny access if the information is not part of the designated record set or if we determine the access could endanger or harm the patient or others.
• We require a patient signature if the patient is 12 years of age or older and information on behavioral health and psychiatric care is requested.
• We require a patient signature if the patient is receiving treatment for reproductive health (including pregnancy and sexually transmitted disease), HIV/AIDS or drug/alcohol use.

Clinics Phone/Fax Numbers