Authorization Forms

Authorization forms are essential for our practice. They allow us to deal directly with other healthcare providers, notify of insurance information, and provide appointment and patient summaries.

Authorization for Release of Medical Records Form – This form is for new patients to request records from previous providers to be sent to Lawrenceville Pediatrics.
Authorization to Release Records – This form is for existing patients requesting records transferred to another practice. There is no fee charged for “basics only” (immunization records, problem list, and growth chart). There is a minimum fee of $25.00 for complete medical records.
Patient Consent for Use and Disclosure of Protected Health Information Form – This form is for all new patients.
Advance Beneficiary Notice – This form is for all patients, and serves to notify you that your insurance provider may not pay for all of the services your child may receive during their visit.

Let Us Know What You Think

Leave Us A Google Review

Welcome Back, Tammie Brickhouse!