Release of Information to Piedmont Pediatrics

Release of Information

Transferring Records TO Piedmont Pediatrics
Please denote what kind of records you are requesting.

Standard RecordsOther
Piedmont Pediatrics will typically only request what we refer to as 'standard records'. These records include notes from the most recent wellness visit (or office visit in general if wellness visit was not performed), immunization records, and growth charts.

If you need any other records need to be obtained other than those noted above, please denote them below.

**PARENTS: PLEASE NOTE IF YOUR CHILD IS OVER THE AGE OF EIGHTEEN, YOU WILL NOT BE ABLE TO SUBMIT A RECORDS REQUEST. PLEASE HAVE THE PATIENT SUBMIT THE REQUEST AS IT WILL HAVE TO BE RELEASED TO THEM.

Who is responsible for submitting this request?*

First & Last NameRelationship to Patient
Phone Number*
Please enter a valid phone number.

By completing this form and providing your signature, you authorizing Piedmont Pediatrics to release medical records for the above patient(s) by means of the selected release methods. The request notated on this form is effective for one (1) year from the signature date unless written revocation is submitted. Any patient under the age of eighteen (18) years of age must obtain a parent/guardian signature. Piedmont Pediatrics will NOT fulfill records requests made by anyone who is not authorized to the patient's health records at the time of the request. Please allow 14 business days for records to be released.
Signature of Patient (if over 18), Parent, or Legal Representative*

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