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MEDICAL RECORD RELEASE FORM

Thank you Evergreen!!!

​To All of Our Wonderful Evergreen Families,

 

My prayers for all of you to have a happy, healthy, vibrant future

 

With the office now closed, if anyone still needs medical records please follow these steps:

 

Please email us at records@mountainpeds.com with your fully filled out and a signed medical records release form along with a copy of your Driver’s License or other picture ID with your current address.  Please allow for a minimum of 14 business days after you have both emailed us with your completed release, and photo id along with finishing your payment online when requesting your records.  I strongly encourage everyone to have the copy of their medical records sent to their home so that they always have them, instead of having to request and pay for them again if you change providers.

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Use the payment tab above to pay for the records you are receiving. Be sure to include the date of birth, and full name for every patient.  Charges for medical records are defined under Colorado State law.  The cost for an abbreviated version of your medical record is $22.50 per patient – this includes the most recent Well Visit, any current medications, your growth charts, and your immunization records, any known allergies to any medication and any recent visits for ongoing medical concerns with our office.  If you would like to have copy of your entire medical record, make an initial payment of $40 per patient and we will notify you based on how large the record is if any additional charges are needed or if you are due a refund per state guidelines.

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Be Safe, Be Kind, Stay Heathy!

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With my heartfelt gratitude,


Dr. Valeri Leswing

Mountain Pediatrics​​

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