This form must be completed by a parent or legal guardian. DO NOT COMPLETE THIS FORM FOR NEWBORN APPOINTMENTS.
Please fill out the survey below with your child's name and the most convenient contact information for us to reach you to schedule your new patient appointment. By completing this survey, you are also authorizing our office to obtain the necessary medical records for transfer.
Please provide your preferred provider choice, as well as a second and third option. We will make every effort to schedule you with your preferred provider if they accept your insurance and have an available appointment. If they are not available, we will schedule you with your next preferred option.
At this time, we are only accepting new patients 12yrs old and younger. 13+ may be accepted with siblings at the provider's discretion.
Please note, this online form does not replace our registration form, which should be completed before your appointment. This form simply allows us to gather as much information as possible to streamline your new patient appointment process. The necessary forms can be accessed on our website or obtained from our offices directly.
RELEASE RECORDS FROM:
RELEASE RECORDS TO:
Partners in Pediatrics
8160 Seaton Place, Montgomery, AL 36116
Phone: (334) 272-1799 Fax: (334) 272-4876
Attached additional Names if Necessary
By signing below, I authorize the use and disclosure of my protected health information as requested. I understand the information may be re-disclosed by the recipient and may no longer be protected by the federal HIPAA privacy rule. I have the right to revoke this authorization except to the extent that Partners in Pediatrics has acted in reliance upon this authorization.
**All records will be provided in electronic format unless requested otherwise.**
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 and you are legally authorized to request transfer of records on behalf of the patient listed above.
This authorization expires 90 days from the date signed.
Medical records received from your previous doctor are reviewed by your Partners in Pediatrics physician. After review your records will be scanned into an electronic health record created for you. If you would like a copy of your records please notify our medical records coordinator, otherwise they will be shredded for your privacy. Thank you!
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