Release Authorization Form – Rising Star Pediatrics

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Authorization for Release of Medical Information

Rising Star Pediatrics · Fax: 561-916-0414 · rspeds.com

PatientRecordsScopePurposeExpirationSignatureReview

✓

Authorization Form Submitted

Your form has been received by Rising Star Pediatrics and a copy has been emailed to our team.

⇩ Open & Save Your Completed Form

🖶 How to save your form as a PDF

👤 For You (Submitter)

Click Open & Save Your Completed Form above — the form opens in a new tab.
Press Ctrl + P (Windows / Linux) or ⌘ + P (Mac) to open Print.
Under Destination or Printer, choose Save as PDF.
Click Save — done. Keep it for your records.

On a phone? Tap the browser’s share icon, choose Print, then save — or use Save to Files (iPhone) / Download as PDF (Android Chrome).

🏥 For Rising Star Pediatrics Staff

The completed form was emailed to [email protected] as an attachment. To save a clean PDF copy:

Open the .html attachment from the notification email.
Press Ctrl + P (Windows) or ⌘ + P (Mac).
Set Destination to Save as PDF.
Under More settings, enable Background graphics so the navy header prints correctly.
Set margins to None or Minimum.
Click Save and file in the patient record.

Chrome or Edge produce the best output. If the layout looks off in another browser, open the file in Chrome first.

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Patient Information

Patient Full Name *

Date of Birth *

Phone Number *

Your Email (to receive a copy)

Address

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Authorization to Release Records — From

Identify the provider or clinic that currently holds the records.

Previous Provider / Clinic *

Provider Phone / Fax *

Records will be sent to

Rising Star Pediatrics · Fax: 561-916-0414

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Scope of Information to Be Released

Select all that apply.

Complete Medical Record
All records including history, exams, and labs

Immunization Records Only

Other

Please specify

Sensitive Information

I specifically authorize the release of information relating to:

Substance Abuse / Alcohol Treatment

Mental Health / Psychotherapy Notes

HIV/AIDS Testing or Treatment

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Purpose of Disclosure

Why are these records being requested?

Transfer of Care / New Patient
Establishing care with Rising Star Pediatrics

Specialist Consultation
Sharing with a specialist or referral

Personal Use
For your own records

Other
Another reason

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Expiration & Revocation

Standard Expiration: This authorization will expire one year from the date of signature unless you specify otherwise below.

Right to Revoke: You may revoke this authorization at any time by delivering written notice to Rising Star Pediatrics, except to the extent that action has already been taken in reliance on this form.

Custom Expiration Date (optional)

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Acknowledgment & Signature

☑ I understand that I am not required to sign this form to receive treatment.

☑ I understand that once information is released, it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

☑ By typing my name below, I understand that this electronic signature has the same legal force and effect as a handwritten signature.

Type Full Name as Signature *

Date *

Relationship to Patient *

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Review & Submit

Please review your information before submitting.

By clicking Submit Authorization, you confirm all information is accurate and consent to the release of the specified medical records to Rising Star Pediatrics.

© 2026

Home
Services
- pricing
- faqs
About
- meet dr. marie
Resources
Forms & Payments
- Medical Records Release
- Pay w/ Zelle