Coastal Pediatric Associates Coastal Pediatric Associates

Forms

Do you need medical information faxed to your child's school or records transferred in from another practice?  

If a patient is under the age of 18, the parents need to fill out Authorization and Disclosure form  if they would like to give anyone other than themselves access to the child's medical record. 

If a patient is 18 or older, the patient must fill out the Authorization and Disclosure form if they would like to give anyone access to their medical record which includes protected health information. This includes giving another person the ability to pick up a prescription, schedule an appointment, discuss health information and the ability to complete the medical record release form.

Medicaid Limited Covid-19 Benefit Plan

We will not be processing any applications at our offices but we wanted to give resource tools on where/how to apply for those who need it.

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Pediatrician On Call Dudek Humphrey
Nursery Calls
  • SFH: Colliton
  • ECMC: Wilson
  • RMPH: Wilson
  • SMC: Colliton
  • TMC:
NEWBORN NOTIFY