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AUTHORIZATION TO USE AND/OR DISCLOSE MEDICAL RECORDS East Lake Pediatrics Phone 727-372-6760 Fax 727-372-6808 Michael Jordan MD Jessica Smith MD Cary Aungst MD Ellyn Theophilopoulos MD Jennifer Leal ARNP Leah McCormack ARNP Rosemarie Rodriguez ARNP I give authorization to the provider listed below to disclose a copy of the specific health/medical information identified below Name of PatientD. Office Notes Active Medication List Immunization Records Problem List Other Records The Following...
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Start by providing your personal information, including your name, address, phone number, and email address.
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Next, provide your insurance information, such as your primary insurance provider, policy number, and any additional coverage you may have.
03
Fill out the patient demographics section, which includes details about the patient's date of birth, gender, and primary language.
04
Provide a complete medical history for the patient, including any current conditions, medications, allergies, and previous surgeries or hospitalizations.
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Fill out the family medical history section, including any history of hereditary diseases or conditions within your family.
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Answer all questions regarding the patient's immunization history, including the dates and types of vaccines received.
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Who needs East Lake Pediatrics?

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Infants and children: East Lake Pediatrics specializes in providing healthcare services for children from birth to adolescence, ensuring their growth, development, and overall well-being.
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Parents and guardians: East Lake Pediatrics is a trusted medical practice that offers guidance, support, and expertise to parents and guardians in managing their child's health and addressing any concerns or questions they may have.
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Families residing in the East Lake area: East Lake Pediatrics serves the local community, offering convenient access to high-quality pediatric care for families living in and around the East Lake region.
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Individuals seeking comprehensive pediatric services: East Lake Pediatrics offers a wide range of services, including well-child visits, vaccinations, sick visits, preventive care, behavioral health evaluations, and more, making it an ideal choice for individuals seeking comprehensive pediatric care.
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East Lake Pediatrics is a pediatric healthcare facility located in the East Lake area.
Only healthcare providers and administrators affiliated with East Lake Pediatrics are required to file.
The forms for East Lake Pediatrics can be filled out online or submitted in person at the facility.
The purpose of East Lake Pediatrics is to provide medical care and services to children in the community.
Information such as patient demographics, medical history, and treatment plans must be reported on East Lake Pediatrics.
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