Patient Transfer Request for Dr. Adam Scott

We are excited to welcome Dr. Adam Scott to the Partners in Pediatrics Family!!!

We are currently in the process of credentialing Dr. Scott within our office. Typically, insurance companies may take anywhere from 3 to 6 months to complete the full credentialing process. Rest assured, we are committed to minimizing any gaps in patient care by promptly scheduling appointments once Dr. Scott's credentialing is approved by the insurance companies.

Upon establishing a start date, we will promptly send a medical record release to Professional Pediatrics to request the necessary records. Subsequently, we will schedule all new patient appointments upon receiving these medical records. We kindly ask for your patience during this process. In the meantime, should you require care, please continue to see the providers at Professional Pediatrics until your records have been transferred.

Please fill out the survey below with your child's name and the most convenient contact information for us to reach you once we've obtained their medical records. By completing this survey, you are also authorizing our office to obtain the necessary medical records for transfer.

Patient First Name

Patient Last Name

Date of Birth

Gender

Male Female

Other (Please Specify)

Primary Insurance

Immunizations up to date?

Yes No

Date of Last Well Child Check-up

Type of Visit (I.e. 2 month well check vs 4yr well check

Has this patient ever been seen at Partners in Pediatrics?

Yes No

Other: (Please Specify)

Parent/Legal Guardian #1

Date of Birth

Other: (Please Specify)

Phone Number (Best Contact Number)

Email address

Street Address

City, State

Zip

Driver's License # / State

Parent/Legal Guardian #2

Date of Birth

Other: (Please Specify)

Phone Number (Best Contact Number)

Email address

Street Address

City, State

Zip

Driver's License # / State

Parent Relationship Status

Single Married Separated Divorced Widowed Fostered Other

AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION

RELEASE RECORDS FROM:

Professional Pediatrics - Attention: Dr. Adam Scott

4154 Carmichael Rd, Montgomery, AL 36106

Phone: (334) 271-5959 Fax: 334-272-8775

Record Inspection or Information Requested

Complete Medical Records

Immunization Records

Referral Summary Notes

Check if Nephrology patient (ONLY)

Other (Specify):

RELEASE RECORDS TO:

Partners in Pediatrics - Attention: Dr. Adam Scott

8160 Seaton Place, Montgomery, AL 36116

Phone: (334) 272-1799 Fax: (334) 272-4876

Reason for Request

Moving/Transferring with Dr. Scott for Continued Care.

Continuing Nephrology Follow-up with Dr. Scott

Patient(s) Name:

Date of Birth

Date of Last Well Child Check-up

Attached additional Names if Necessary

Patient(s) Name #2:

Date of Birth

Date of Last Well Child Check-up

Patient(s) Name #3:

Date of Birth

Date of Last Well Child Check-up

Patient(s) Name #4:

Date of Birth

Date of Last Well Child Check-up

Patient(s) Name #5:

Date of Birth

Date of Last Well Child Check-up

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.**

Indicate Preference:

Electronic Form/Fax

Please Mail to Partners in Pediatics

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.

Printed Name

Relationship to Patient

Phone Number

Please upload Copy of Driver's License & Insurance Card

Add file

Please upload a file

Date Signed

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.