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English (US)
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Hamilton Mill Pediatrics Medical Records Release Form
3619 Braselton Hwy Suite 103 Dacula GA 30019 P: 770-513-8882 F:770-513-3545
Name of Patient
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Date of last Check Up/Physical Exam (if your baby is a newborn please put the date of hospital discharge)
*
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Month
-
Day
Year
Date
Please fill out the following information so we can request/send records
*
I authorize Hamilton Mill Pediatrics to OBTAIN my records from:
I authorize Hamilton Mill Pediatrics to SEND my records to:
Name of office/person to send records to
*
Address of office
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
Please enter a valid phone number.
Office Fax Number
Please enter a valid phone number.
Email
If transferring out of Hamilton Mill Pediatrics, please indicate why:
Moving
Unsatisfied with practice
Insurance/PCP change
Other
How would you like your records sent? Please note there is a $15.00 fee for printing records.
*
Fax to new office
Email
Mail to my home address ($15.00 fee)
Pick up in office ($15.00 fee)
**Please do not send faxes larger than 20 pages in a single fax**
Signature
*
Continue
Continue
Should be Empty: