Sample Release of Information Form
Date: Dear: I, birth date is , the parent/legal guardian of,
(Child’s Name)
whose
, am requesting copies of medical records/school records from
(School, Physician or
for the following dates:
Hospital name)
Please mail this information to the following address:
Signed:
(Parent/Legal Guardian) (Date)
65 | CARE COORDINATION NOTEBOOK: FINANCING AND MANAGING YOUR CHILD’S HEALTH CARE April 2005 | Chapter 11 | Forms for Advocating Your Child |
Virginia Care Coordination Notebook developed by Parent to Parent of Virginia