PATIENT TRANSFER OF MEDICAL RECORD

Please fill out your child's former physician or hospital information.

Name of former doctor or hospital:

Address:

Phone

Fax

I hereby authorize and request the release of my child's records
(Please only send the following)

Growth Charts, Immunization Records and Last Physical Examination to:

Northeast Pediatric Associates, P.C.
Barclay Medical Plaza
75 Barclay Circle, Suite 115
Rochester Hills, MI 48307

Patient's Name:

Date of Birth:

Parent or Guardian:

Home Address:

Phone #

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

SIGNATURE OF PARENT OR GUARDIAN

DATE

Patient Information & Benefits Record Release:

DATE

Check All That APPLY: (This question is asked to better diagnose medical issues that are assoclated with specific ethnic groups. Please circle your child's ethnicity; we are complying with the policies of your insurance company.)

HISPANIC

LATINO

AFRICAN AMERICAN

Caucasian

Preferred Language Spoken at Home

PATIENT INFORMATION

Add Child

MOTHER/GUARDIAN #1

LAST NAME

FIRST NAME

DOB

Address

Apt.#

City

State

Zip Code

Primary Cell Phone

Secondary Contact Phone

Email address

FATHER/GUARDIAN #2

LAST NAME

FIRST NAME

DOB

Address

Apt.#

City

State

Zip Code

Primary Cell Phone

Secondary Contact Phone

Email address

Pharmacy Name

Address

Zip

Which parent will be receiving appointment reminders?

Mother/Guardian #1

Father/Guardian Financially #2

Financially Responsible Parent/Guardian for Patient?

Mother/Guardian #1

Father/Guardian Financially #2

If Divorced/separated what is the primary address for the child?

# 1

# 2

Permission to Release Medical Information to Parents:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Young Adult (over 18 years of age)

Patient Cell

EMERGENCY CONTACT INFORMATION

Please list the information for an emergency contact living outside your home.

Relation to child

Last Name

First Name

Phone Number

FAMILY HISTORY

DATE:

PARENTS NAME:

Add new row

ANY HEALTH ISSUES IN YOUR CHILDREN:

PLEASE INDICATE ANY OF THE FOLLOWING THAT MAY AFFECT A MEMBER OF YOUR FAMILY:

Please Select ALL that apply

Add new row

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