MEDICAL RECORDS WILL BE RELEASED TO: LITTLE VILLAGE PEDIATRICS, LLC12740 Meeting House RoadCarmel, Indiana 46032PHONE: 317 343 8844FAX: 540 274 8548
PURPOSE OF DISCLOSURE: CONTINUITY OF CARE
DATES OF INFORMATION TO BE DISCLOSED: FROM blanks to blank.
We are requesting this information for the continuity of care for the patient listed above. This request is in compliance with 45 CFR 164.506 of the Health Insurance Portability and Accountability Act (HIPAA) which allows the release of information without explicit patient consent for treatment purposes.
NAME OF PERSON/OFFICE REQUESTING : LITTLE VILLAGE PEDIATRICS (PHYSICIAN