Authorization For Release Of Medical Records From Ivy Pediatrics 2026

1. Click ‘Get Form’ to open the Authorization For Release Of Medical Records in the editor.
2. In the 'Release From' section, enter the clinic's name, address, city, state, zip code, and telephone number. This information identifies where the records are being released from.
3. Next, specify the patient(s) for whom you are requesting records. Fill in each patient's name and date of birth (DOB) in the designated fields. Ensure accuracy to avoid any delays.
4. In the 'Records Requested' section, clearly indicate that you want the immunization record, growth chart, last physical exam, pertinent labs & specialist reports only. This helps streamline what is needed.
5. Finally, sign and date the form at the bottom as a parent/guardian/patient to authorize the release of these medical records.

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