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AUTHORIZATION TO RELEASE INFORMATION Capitol Pediatrics & Adolescent Center, LLC Phone # 9197825273 I hereby authorize to use or disclose the specific information described below to the parties and
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How to fill out Capitol Pediatrics & Adolescent form:

01
Start by entering the patient's general information such as their name, date of birth, gender, and contact details.
02
Provide the patient's medical history including any existing conditions, allergies, and medications they are currently taking.
03
Fill in the details of the patient's primary care physician or referring physician, if applicable.
04
Include information about the patient's immunization history, noting the vaccines they have received and the dates they were administered.
05
Provide details about the patient's family medical history, including any hereditary conditions or diseases that run in the family.
06
If the patient has any current symptoms or complaints, describe them in detail and indicate when they started.
07
Note any recent hospitalizations, surgeries, or other significant medical events the patient has experienced.
08
Fill out the insurance information section, including the name of the insurance provider, policy number, and any necessary authorization details.
09
Sign and date the form to indicate that the information provided is accurate and complete.

Who needs Capitol Pediatrics & Adolescent:

01
Infants and children: Capitol Pediatrics & Adolescent provides medical care for infants, children, and adolescents up to 18 years of age. Parents or legal guardians can seek their services to address their child's healthcare needs.
02
Adolescents: As the name suggests, Capitol Pediatrics & Adolescent specializes in healthcare services tailored to meet the needs of adolescents. Teenagers and young adults can benefit from their expertise in adolescent medicine.
03
Families: Capitol Pediatrics & Adolescent focuses on providing comprehensive and family-centered healthcare. They cater to the healthcare needs of the entire family, ensuring each member receives appropriate care and support.
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Capitol Pediatrics & Adolescent is a medical clinic that provides healthcare services for children and adolescents.
Patients or their guardians are required to fill out capitol pediatrics & adolescent forms when seeking medical services.
To fill out the forms, patients need to provide their personal information, medical history, and insurance details.
The purpose of capitol pediatrics & adolescent forms is to gather relevant information about the patient for medical treatment.
Patients must report their personal details, medical history, current symptoms, medications, and insurance information.
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