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Get Pediatric Medical Records

F Birth: Address: City: State: Zip: Please mail or fax records to: ATTN: Medical Records Fort Payne Pediatrics 1906 Glenn Blvd SW Ste 100-A Fort Payne, AL 35968-3546 (P) 256.997.5900 (F) 256.997.5995 The signature below serves as authorization to transfer the records. Because the patient is younger than age 18, my signature serves as authorization. The patient is: My child Other dependent Authorized Signature: Date: Because the patient is age 18 or older, the patient s.

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The times of distressing complex legal and tax forms are over. With US Legal Forms the entire process of submitting official documents is anxiety-free. The leading editor is right at your fingertips offering you a range of beneficial instruments for submitting a Pediatric Medical Records. These tips, together with the editor will assist you through the entire procedure.

  1. Click on the orange Get Form option to start enhancing.
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  5. Indicate the date to the sample using the Date function.
  6. Click the Sign button and create a signature. You can find 3 available choices; typing, drawing, or capturing one.
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  8. Select Done in the top right corne to save and send or download the file. There are several choices for getting the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

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  • Pediatrics
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