Records Transfer Form

Patient Name *

First

Last

D.O.B. *

Date of Birth (xx/xx/xxxx)

Please send information, including diagnosis and records of any treatment or examination rendered. Por Favor de enviar informacion de diagnosis y record de todo tratamiento o examen realizado.

To: L&J Pediatrics, PA

20338 NW 2nd Ave, Miami, FL 33169, TEL (305)-770-1937, FAX (305)-770-1468

From:

Please indicate from whom the Records will be coming from.

Please send information, including diagnosis and records of any treatment or examination rendered. Por Favor de enviar informacion de diagnosis y record de todo tratamiento o examen realizado.

From: L&J Pediatrics, PA

20338 NW 2nd Ave, Miami, FL 33169, TEL (305)-770-1938, FAX (305)-770-1468

To:

Please indicate to whom we will be sending Records to.

I hereby authorize you to release information including the diagnosis and records of any treatment or examination rendered to L&J Pediatrics, Pa. I am aware that the records released may contain information relating to physical testing, physical abuse, or drug and/or alcohol abuse. He aqui doy mi autorizacion para la transferencia de informacion medica, inclusive el diagnosis y record de todo tratameinto o examen relizado, a L&J Pediatrics, PA. Reconozco que es posible que la record transferida contiene informacion prueba fisica, abuso fisico, o abuso de drogas o de alcohol. *

Yes, I authorize

Name of Parent/Guardian *

First

Last

Comment

Medical Records Transfer Form

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