Release of Medical Records Please fill out and submit this consent to release information form online. Thank you, Pediatric Potentials, LLC Order Number Pediatric Potentials Occupational Therapy Services Consent to Disclose Medical Records Name * Email Address * The patient authorizes to disclose all or any part of the patient’s medical or financial records to any person or entity which is or may be liable under contract to this clinic, to the patient, or to a family member or employer of the patient to pay all or a portion of the cost of care provided to the patient, including but not limited to, hospital or medical service companies, health care companies, insurance companies, worker’s compensation carriers, welfare funds, or the patient’s employer or the clinic’s auditors. All information obtained will be kept private and used only for the planning of services or for billing for services provided from Pediatric Potentials. List all service providers that may be contacted by Pediatric Potentials for records, medical information (e.g. physicians, schools, other therapy providers, hospitals, etc.) Provider 1 Please provide provider's name, address, phone #, and information type here Provider 2 Please provide provider's name, address, phone #, and information type here Provider 3 Please provide provider's name, address, phone #, and information type here Provider 4 Please provide provider's name, address, phone #, and information type here Provider 5 Please provide provider's name, address, phone #, and information type here Thank you for providing this information to Pediatric Potentials. We will review the information and look forward to seeing you at your appointment. At that time we will request signatures or additional information as needed.
