FORM REQUEST GUIDELINES:
Submitting a form request in the portal (USING THE ‘CREATE MESSAGE‘ BUTTON):
RECORDS REQUEST PROTOCOL:
You may request for records to be release to/from Piedmont Pediatrics utilizing our release forms below.
If you are leaving the practice, need records for personal use, or are continuing care with a specialist, please utilize the Release of Records FROM Piedmont Pediatrics form.
If you would like Piedmont Pediatrics to request records on the patient’s behalf, please utilize the Release of Records TO Piedmont Pediatrics form.
After completing your records release form, you may submit it via the My Kid’s Chart portal or email it to medical.records@piedmontpediatrics.org
You can access the patient portal here:
You may complete this form if you have not been signed up for our patient portal. Piedmont Pediatrics must enable access manually from our end, so please allow at least 24 hours to receive your portal activation confirmation.
For your convenience, we have provided various forms below that you may download, complete your portion, and re-upload into the portal for physician review. Please do not submit blank forms for physician review or your request will be denied and returned. If you have your own forms needing to be uploaded, you have the opportunity to do so in the Forms Request function of the patient portal. Please see these forms below
Download
RELEASE OF RECORDS TO PIEDMONT PEDIATRICS
Download
RELEASE OF RECORDS FROM PIEDMONT PEDIATRICS
For those looking to obtain records from Piedmont Pediatrics if you are changing practices, seeing a specialists, or to request records for personal use.Download
Patient Communication Consent
Download
Parental Authorization (18yo patients)
Download
Annual Administrative Fee 1
Download
Refusal to Vaccinate Form
Download
Asthma Control Test Ages 4 to 11 years of Age
This form is for children between 4 and 11 years of age.Download
Asthma Control Test Ages 12 years and Older
This form is for children 12 years of age and older.Download
Advance Beneficiary Notice of Noncovered Services
Download
Allergy Immunotherapy Informed Consent Form
Download
Allergy Patient History Questionnaire
Download
Allergy Serum Mixing Consent Form