Release of Medical Records
If you would like to release patient records from Pediatric Surgical Associates to a different clinic, provider or person, please fill out the form below.
If you would like to release patient records to Pediatric Surgical Associates from a different clinic, provider or person, please fill out the form below.
Medical Authorization for Non-Custodial Adults
If you are the legal guardian of a child who is authorizing another non-custodial adult to accompany the child to their medical appointments at Pediatric Surgical Associates as well as discuss personal health details and history with our health care professionals, please download, complete and sign this form. The person(s) you are designating must bring this completed form with them to the child’s upcoming medical appointment. Note: Once signed, this form is effective indefinitely or upon notice of the legal guardian to cancel, change or amend it.
To view the forms listed, you will need Adobe Reader. Please bring your completed forms with you to our office at the time of your visit.