Medical Records Request · Starter Portal

Medical Records Request

Patient Information:

Patient First Name:

Patient Last Name:

Patient Date of Birth (M/D/YYYY):

Does this patient have a Patient Portal account with PM Pediatric Care? Please note, this is different from your PM Pediatrics Anywhere telehealth account.

NoYes

Requestor Information:

Person Requesting Record First Name:

Person Requesting Record Last Name:

Relationship to Patient of Person Requesting Records:

Request Records Description:

Description of exactly what records you are looking for **If you are looking to retrieve your COVID test results or other lab results, please visit your patient portal or call the office where you or your child received the test. **

Patient/Parent/Guardian Email Address:

Primary Contact Number (###-###-####):

By clicking this box, I affirm that I am the patient who is the subject of this medical records request or, for patients under 18 years old, I am the parent, legal guardian, or authorized legal representative of the patient who is the subject of this medical records request. I hereby attest an affirm that I am entitled to request and received this information on the patient's behalf, and that this legal authority has not been limited or revoked by court order, divorce decree, or other law.

Yes I affirm