Ball Pediatrics Form to Release Medical Records

Ball Pediatrics Form to Release Medical Records

3619 Braselton Hwy Suite 103 Dacula GA 30019 P: 770-513-8882 2610 HWY 129 N Jefferson GA P: 762-393-0111
Please note this form is intended for use of releasing your records from Ball Pediatrics to another healthcare provider or entity when transitioning care or coordinationg care.
Today's Date

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I am requesting the following medical records:*

Basic Record Request (to include summary of care, last well check notes/last visit note, vaccine records, recent labs/imaging as applicable)Complete patient record (note a fee may incur)
Please note that Ball Pediatrics does not charge for Basic Medical Records that are faxed or emailed. Complete Medical Records can be emailed for no additional fee. Complete medical records are often too large to fax; therefore they cannot be faxed. For the printing of medical records, there is a $20 fee that is due at time of pick up.
Why are you requesting records?*

Coordination of careInsurance/PCP changeUnsatisfied with practiceMovingOther
Where are we sending your records?
Facility/Individual name *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax number *
Please enter a valid phone number.
Email*
example@example.com
Email*
example@example.com
Signature of patient or personal representative who may request disclosure (patient over the age of 18 must sign themselves).

By signing below, you authorize your healthcare provider identified above to release your proteted health information, and ackowledge and understand the terms of the request for access to and authorization for Use and Disclosure of protected health information.
Patient/ Parent or Guardian Name*

First NameLast Name
Relationship to patient *
Signature of patient/parent or guardian *

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Date of Signature

MonthDayYear
Date
Please provide photo ID*

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Ball Pediatrics Form to Release Medical Records

Where are we sending your records?