Patient Transfer Request for Dr. Adam Scott

For CURRENT patients of Dr. Scott requesting transfer of records from Professional Pediatrics to Partners in Pediatrics. Do NOT complete this form if you are requesting to transfer to Dr. Scott from another office.

Please correct the errors described below.

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.



Professional Pediatrics - Attention: Dr. Adam Scott

4154 Carmichael Rd, Montgomery, AL 36106

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


Partners in Pediatrics - Attention: Dr. Adam Scott

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.