Release of Information Request to LaTouche Pediatrics (pdf) 2026

1. Click ‘Get Form’ to open the Release of Information Request in our editor.
2. 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.
3. Fill in the Address and Primary Caregiver's name to ensure accurate communication.
4. 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.
5. 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.
6. Indicate the Date Range for which you are requesting information if applicable.
7. Select the purpose for this request from options like Treatment or Personal Records. If any protected information is involved, initial next to those categories.
8. 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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