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Our Lone Tree Pediatricians at Lone Tree Pediatrics 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's legal name, including last, first, and middle initial, along with their date of birth in the specified format (mm/dd/yyyy).
- In the 'FROM' section, confirm that 'Lone Tree Pediatrics' is pre-filled. In the 'TO' section, provide the recipient's name, address, phone number, and email as required.
- Select a reason for releasing Protected Health Information by checking one of the options provided: Transfer of Primary Care, Personal, or Other.
- Indicate how the records will be released by checking either for pick-up by a parent/guardian or mailing/FAXing to another provider.
- Choose the type of information to be released by selecting from options such as a copy of the entire chart or specific health information related to treatment.
- Finally, ensure you read and understand all consent statements before signing and dating the form at the bottom.
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