New Patients Release Form

Fill out the form below or click the download button to print and fill out the form at home and bring in to the front desk.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Patient Name
First Middle Last
Phone Number
Email
Date of Birth
MM slash DD slash YYYY
I hereby authorize and request:
Name of Physician or Medical Facility:
Address
Street Address City State / Province / Region ZIP / Postal Code
To release to:
St. Clair Pediatrics, LLC 4941 Benchmark Centre Dr. Suite 100 Swansea, IL 62226
Medical Records covering the periods from:______
MM slash DD slash YYYY
To:______
MM slash DD slash YYYY
Requested medical information is needed for:
Reason for transfer:
- Relocation
- Non-Participation with Insurance
Medical records may be faxed to: 618-624-9973
I understand that my medical records or the medical record of the patient for whom I am signing may include Alcohol/Drug abuse, Psychiatric treatment or HIV/AIDS testing or treatment and are covered by Federal Regulations and cannot by disclosed without my written consent, unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that prior action has been taken on it. In any event, this consent will expire ninety (90) days from the date the authorization is signed. St. Clair Pediatrics, LLC, its employees, officers and physicians are hereby released from all legal liability or responsibility for the release of the records to the extent indicated and authorized herein.
I understand and accept the above statement.
- I agree
Patient/Responsible Party Name
First Middle Last
Relationship to Patient
Date
MM slash DD slash YYYY

What Our Families Are Saying

Hollie H.

Dr. Garrison and his staff are just the best!!!! I could not ask for a better pediatrician for my son!! I would highly recommend them to anyone!

Catrina H.

We just switched to them and I’m so glad we did! The office is beautiful and clean and everyone there is very friendly and helpful.

Karen R.

As stressful as it can be to bring your sick child into the pediatrician’s office, the staff at St. Clair Pediatric’s always know how to provide a calm & comforting environment! The care provided by their staff is nothing short of spectacular.