Medical Records Releases

Medical Release Forms

These forms allow us to send or request information about your child to or from another office that you specify.

There are four ways to submit forms:

Complete the forms through our secure, online system using the link below. PLEASE NOTE: On some systems, you may receive a 404 error message after submitting an online form. The form is still submitted and you will receive a copy at the email and/or phone number that you entered in the first step. We are working to resolve the error message, but it does NOT affect the secure online form submission.
Request an email or text with a link to a secure online form that you can fill out on your phone or computer and return safely to us. To request an online form, call us at 770-429-1005
Print the forms and fax them to us at 770-429-8005, drop them off, or mail them to 3745 Cherokee St, NW, Kennesaw GA 30144.
Come into the office and complete printed forms there.

The MEDICAL RECORDS RELEASE FROM KP allows us to send information FROM KP to another person or office. We would need this form on file if you wanted us, for example, to send an immunization form to daycare, send lab results to a specialist, or send a school excuse to your child’s school. Each type of request needs a separate form, but you can keep a form on file for a year IF it’s the same information released to the same person. For example, to send immunization forms for daycare.

To print the form click here: Medical Records Release FROM KP 2018

To complete the form through our secure online system, click here: Online Medical Records Release FROM KP

The MEDICAL RECORDS RELEASE IN TO KP allows us to request information be sent TO KP from another person or office. We would need this form on file to request records from a specialist, school, or previous pediatrician.

To print the form click here: Medical Records Release IN to KP 2018

To complete the form through our secure online system, click here: Online Medical Records Release IN to KP