ONLINE REQUEST FOR NEW PATIENT APPOINTMENT

This form must be completed by a parent or legal guardian.

Please correct the errors described below.

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.

All of our providers work between each office.
    Please upload a file
      Please upload a file
      To receive information about appointments and updates
        Please upload a file

        AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

        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

        Record Release Authorization

        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.

          Please upload a file

          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!

          Your information will be encrypted.

          Loading...