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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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