Providing specialized healthcare for infants, children, and adolescents

Prescription Form

For Community Health Pharmacy

Release Form

For Substance Use Treatment and Mental Health Information

Release Form

For General Medical Records

Statement of Disagreement

for Denial to Amend my Protected Health Information

Request For Amendment/ Correction

of Protected Health Information

Request for Accounting of Disclosures

of Protected Health Information

Request for a Specified Method

of Preferred Communication

Request for Restriction

on Use and Disclosure of Protected Health Information

Motor Vehicle Accident

Insurance & Consent to Release Medical Records Form

Workers
Compensation

Verification and Consent to
Release Medical Records Form

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Financial Assistance

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Bill Payment Portal

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Patient
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