Request For Medical Records


       
 
Name   Email  
/ /
Address   City / State / Zip
Date of Birth   Social Security Number Phone Number
       
       
I hereby authorize release of my medical records TO / FROM:  
       
   
Name      
/ /
Address   City / State / Zip
   
Phone Number   Fax Number  
       
       
Reasons records are being requested for:    
       
Insurance claim Review by attorney Care by physician  
Disability Continuing care Other (Please specify):
       
       
 
Person (or Legal Guardian) Name   Date
       
 
Witness Name   Date
       
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Pediatric services are available to all children; office visit fees can be billed to medical insurance or paid in cash.
A sliding schedule of fees for uninsured children is available. Contact us now for more information.
The information contained in this website is to provide information of a general nature about the
practice and pediatric medical conditions. Neither Dr. Leonhardt nor Bee Well Pediatrics, P.A. is engaged in rendering medical
advice or recommendations. You should always consult your doctor for advice.