Get Fort Wayne Pediatrics

Filling out the Fort Wayne Pediatrics medical records release form online is a straightforward process. This guide provides clear and structured instructions to ensure you complete the form correctly and efficiently.

Follow the steps to successfully fill out the form

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter the date at the top of the form in the designated field.
3. In the 'Patient Name(s)' section, write the name(s) of the patient(s) whose records you wish to release.
4. Next, enter the 'Patient(s) Date of Birth' for each individual listed to ensure correct identification.
5. Select the type of information to be released by checking the appropriate box: 'All records' or 'Immunizations Only.'
6. Fill in the 'Release From' section, noting the name of the physician(s) and the respective address from which records will be obtained.
7. In the 'Release To' section, add the name and address where you want the medical records sent.
8. Indicate the purpose for the release by checking the corresponding box that applies to your situation.
9. Sign the form as the parent or guardian, and indicate your relationship to the child.
10. Provide your current address and phone number in the designated fields to ensure accurate communication.
11. Review the information entered for accuracy before completing the process.
12. Once you have completed the form, you may save your changes, download, print, or share the document as needed.

Complete your documents online today to streamline the process.