Appendix_E

Study to Explore Early Development

Please use this form to provide medical records release for your prenatal care medical record.

If you received prenatal care from more than one health care provider, please fill out a separate form for each prenatal care provider.

For each form you complete:

Fill out your name and identifying information in the top section.

Fill out the name of the individual provider or provider group on the line stating, “I authorize the following individuals or organizations to make this disclosure”

Review and complete the entire form and sign and date the form on the second page.

Study to Explore Early Development

Please use this form to provide medical records release for your labor and delivery medical record.

If your labor and delivery occurred at more than one hospital (this happens sometimes because of patient transfers), please fill out a separate form for each hospital that provided you care during labor and delivery.

For each form you complete:

Fill out your name and identifying information in the top section.

Fill out the name of the hospital on the line stating, “I authorize the following individuals or organizations to make this disclosure”

Review and complete the entire form and sign and date the form on the second page.

Study to Explore Early Development

Please use this form to provide medical records release for your child's neonatal care medical record.

If your child received early infant care at more than one hospital (that is, hospital care from birth until discharge to go home – more than one hospital happens sometimes because of patient transfers), please fill out a separate form for each hospital that provided care to your child just after he or she was born.

For each form you complete:

Fill out your child’s name and identifying information in the top section.

Fill out the name of the hospital at which your child received early infant care on the line stating, “I authorize the following individuals or organizations to make this disclosure”.

Review and complete the entire form and sign and date the form on the second page.

Study to Explore Early Development

Please use this form to provide medical records release for your child's pediatric care medical record from birth to age 3 years.

If your child received pediatric care from more than one provider during his or her first 3 years, please fill out a separate form for each pediatric provider.

For each form you complete:

Fill out your child’s name and identifying information in the top section.

Fill out the name of the individual provider or provider group on the line stating, “I authorize the following individuals or organizations to make this disclosure”

Review and complete the entire form and sign and date the form on the second page.

Study to Explore Early Development

Please use these forms to provide medical records release for your medical record at all other healthcare providers that you (the biological mother) received care from during the three years before your child's birth. Do not use this form for your prenatal care provider.

Other healthcare providers to think about are primary care providers, allergist/immunologists, rheumatologists, psychiatrists, and infertility specialists.

Fill out a separate form for each provider.

For each form you complete:

Fill out your name and identifying information in the top section.

Fill out the name of the individual provider or provider group on the line stating, “I authorize the following individuals or organizations to make this disclosure”

Review and complete the entire form and sign and date the form on the second page.

Study to Explore Early Development

Please use these forms to provide medical records release for your child’s medical record at all specialist healthcare providers from whom your child received care from birth to age 3 years.

Specialist healthcare providers to think about are developmental pediatricians, allergist/immunologists, psychiatrists, and neurologists.

Fill out a separate form for each provider.

For each form you complete:

Fill out your child’s name and identifying information in the top section.

Fill out the name of the individual provider or provider group on the line stating, “I authorize the following individuals or organizations to make this disclosure”

Review and complete the entire form and sign and date the form on the second page.

Study to Explore Early Development

E XTRA FORMS

Version 9-07 SNC Page 1 of 1