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Release of Information Request to LaTouche Pediatrics (pdf) 2026
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- Click ‘Get Form’ to open the Release of Information Request in our editor.
- Begin by entering the Patient Name and Date of Birth in the designated fields. If the patient is under 18, include the Parent/Guardian Name and their Phone Number.
- Fill in the Address and Primary Caregiver's name to ensure accurate communication.
- In the 'Release TO' section, confirm that LaTouche Pediatrics, LLC is listed correctly. For 'Release FROM', provide the necessary details including Phone Number, Fax Number, and Address.
- Specify the information requested for release by selecting either 'Entire Chart' or 'Specific Information'. If choosing specific information, check all applicable boxes such as Chart Notes or Lab Reports.
- Indicate the Date Range for which you are requesting information if applicable.
- Select the purpose for this request from options like Treatment or Personal Records. If any protected information is involved, initial next to those categories.
- Finally, print your name, relationship to the patient, sign and date at the bottom of the form. Ensure that if the patient is over 18, they sign instead of a guardian.
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