Laramie Pediatrics, pc

Welcome to the online office of Laramie Pediatrics, pc

______________LARAMIE PEDIATRICS/INTERNAL MEDICINE______________________

                                    1252 N 22^nd St.  Laramie, Wy  82072

                        AUTHORIZATION TO RELEASE MEDICAL RECORDS

I hereby authorize the transfer of all the medical records in your possession(including copies of medical records from other Physicians,Clinics/Hospitals, and Specialists.

PATIENT:____________________________________________DOB_________________

PATIENT:____________________________________________DOB_________________

PATIENT:____________________________________________DOB_________________

PATIENT:____________________________________________DOB_________________

                               FROM                                          TO

___________________________________           _________________________________

(Name)                                                                    (Name)

___________________________________           _________________________________

(Complete address)                                                  (Complete address)

___________________________________           _________________________________

(City)                           (State)             (Zip)             (City)                             (State)         (Zip)

___________________________________           _________________________________

(Phone number)                                                         (Phone number)

___________________________________           _________________________________

(Fax number)                                                             (Fax number)

REASON FOR LEAVING(optional)___________________________________________________

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.

RESPONSIBLE  PARTY’S SIGNATURE:___________________________DATE__________ 

Address:_________________________City:__________________State:_______Zip__________

Phone Number:_____________________________

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