Request a Form or Referral

Electronic Request via Patient Portal

Many requests for records can be made through our patient portal. These include requests for referrals, immunization records requests and hearing and vision records requests. Simply sign into the patient portal and send us an email request for any of these items.

Referral Request – To complete this form you will need the following information about the specialist you are being referred to: specialist’s name (or if scheduled with a physician’s assistant or nurse practitioner, their supervising physician), date of the appointment, address and phone / fax number of practice.

Immunization Records Request (3231) – If this will be released to an outside organization, you’ll also need to complete the Medical Records Release FROM KP.  This form requires 48-72 hours for completion.   This is a state form that certifies a child is up to date on immunizations, therefore your child must be fully up to date on all required immunizations for us to issue this form.

Hearing and Vision Records Request (3300)– If this will be released to an outside organization, you’ll also need to complete the Medical Records Release FROM KP.  This form requires 48-72 hours for completion. For us to complete this form, your child MUST be up to date on their well-child visit AND have a valid hearing and vision exam within the last 12 months.

Katie Beckett Forms

These require 7-14 business days for completion. Your child must be up to date with their well child exams and have any/all supporting documentation from specialists, labs, therapist, and counselors on file with Kennesaw Pediatrics. These comprehensive forms require a great deal of time and review.  You are responsible for ensuring all appropriate documentation is present at the time of your request. Please note, that successful filing of a Katie Becket Waiver makes the child eligible for Medicaid. Since Kennesaw Pediatrics cannot accept Medicaid, you may need to have a new pediatrician lined up for a smooth transition of care in order to fully utilized Katie Beckett benefits.

Family Medical Leave Act (FMLA) Form

This form requires 7-14 business days for completion.

FORM FEES

Immunization Records (3231) are provided at each well check, free of charge.  Hearing and Vision Forms (3300) are also provided free of charge at any visit in which hearing and vision are checked.  Sports or camp forms brought to the exam are also completed free of charge. Replacement 3231 or 3300 forms,  or other forms that are dropped off for completion at a time other than an exam, are $10 per form.   Because of the substantial time involved in completion, initial Katie Beckett applications are $75.