Forms

To transfer medical records, please fill out this form: Lafayette Pediatrics and Internal Medicine Release of Information

To transfer medical records from KAISER PERMANENTE, please fill out this form instead: Kaiser Permanente Release of Medical Information and forward to Kaiser.

Prior to your visit, please fill out these forms and bring them in:

1. HIPPA Patient Consent

2. HIPPA Acknowledgement of Receipt of Privacy Practices

3. Patient Information Sheet

4. Patient Policies

5. Adult Health History

6. Pediatric Health History

 

To view our HIPPA Policies, please click here:

HIPPA Notice of Privacy Practices