*Required fields are marked with an asterisk.

Medical Record Release

Loading Please wait

You will need to fill out a Medical Record Release Form for each child. 

I authorize Altamonte Pediatric Associates to obtain or release medical information concerning the patient listed below.








Send the records to the following facility or self (Parent, Legal Guardian, or Patient if 18 years of age or older)








*Pursuant to Florida Administration Code 64B-10.003 we reserve the right to charge for the release of medical records.

Records are to be sent to:

Altamonte Pediatric Associates

(407) 831-6200

475 Osceola Street #1100

Altamonte Springs, FL 32701

Fax (407) 831-1068

 

I understand that this consent is revocable upon written notice to the office where the original authorization is retained, except to the extent that action has already been taken on this authorization, and that the office has been taken in reliance on this authorization, and that consent shall remain for one year unless otherwise specified in order to affect the purpose for which it is given. Mental health, alcohol, drug abuse, HIV, & or AIDs information is confidentially protected by Federal and State Law which prohibits disclosure without specific written authorization of the undersigned, or as otherwise permitted by such regulations.

I, the requester for this medical record release, warrant the truthfulness of the information provided in this form. 



PLEASE NOTE: Any patient 18 years of age or older must sign his/her own medical release. 




Please enter a custom answer