Laramie Pediatrics, pc

Welcome to the online office of Laramie Pediatrics, pc

Authorization for Medical Records Release

Please feel free to download this record release form, fill it out and bring it with you to your first office visit. This will speed up your filling out paperwork at the first office visit.

I hereby authorize __________________________

                              __________________________

                              __________________________

to transfer all the medical records in your possession ( including copies of Medical records from other Physicians and Clinics/Hospitals, specialists who delivered medical care, Immunizations records, letters to or from other Physicians relative to the medical care delivered to the below named Patients) to:

Laramie Pediatrics, PC

Dr. Kent Kleppinger, MD

1252 North 22^nd Street, Suite "B"

Laramie, Wyoming 82072

Patient Name:                                                                          DOB

I hereby release _______________________ and its staff from any and all legal responsibility or liability that may arise from the release of this form or these Medical Records.

 Parent or responsible Party’s signature:______________________

 Relationship to Patient : ___________________________

 Address :  ________________________    Date : ________________

 City: ______________________ State:  ____________ Zip: _______

 Phone Number:  ________________________

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Send mail to Klep@Laramiekids.com with questions or comments about this web site.