Ball Pediatrics Form to Obtain Medical Records

Ball Pediatrics Form to Obtain 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 to give Ball Pediatrics authorization to obtain your records from 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 my complete medical record (to include last visit notes, last well check, vaccine records, recent labs/radiology) to be sent to Ball Pediatrics my means below: (choose one)*
**please note there may be a fee associated with release of records. Please contact your prior office to inquire**
Where are we obtaining records from?

(Please note the following fields refer to your prior medical home so we may send this release on your behalf)
Prior office/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.
Why are you transferring records?*

Insurance/pcp changeCoordination of careNot happy with prior officeOther
Signature of patient or personal representative who may request disclosure (patient over the age of 18 must sign themselves).
Patient/Parent or guardian Name*

First NameLast Name
Relationship to patient *
Signature*

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Date of Signature

MonthDayYear
Date
Please provide Photo ID*

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Ball Pediatrics Form to Obtain Medical Records

Where are we obtaining records from?