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Avoiding the Flu
Vaccine facts and safety
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What do I do if a person in my
home has the H1N1 (swine flu)?
What every parent should know about RSV
Car Seat Safety Information
What you need to know about Allergies and Asthma
2715 Osler Drive,
Grand Prairie, Texas 75051
Tel: 972-206-2940
Fax: 972-602-7261
Email : pacgpa@emcaturaymd.com
Normal Office Hours:
Monday – Friday
8:00 a.m. – 5:00 p.m.
Extended Office Hours:
Saturday 9:00a.m - 3:00p.m
Avoiding the Flu
Vaccine facts and safety
information
What do I do if a person in my
home has the H1N1 (swine flu)?
What every parent should know about RSV
Car Seat Safety Information
What you need to know about Allergies and Asthma
2715 Osler Drive,Grand Prairie, Texas 75051
Tel: 972-206-2940
Fax: 972-602-7261
Email : pacgpa@emcaturaymd.com
Normal Office Hours:
Monday – Friday
8:00 a.m. – 5:00 p.m.
Extended Office Hours:
Saturday 9:00a.m - 3:00p.m
Terms and Conditions
Submission of this form does not ensure delivery. If staff from Pediatric and Adolescent Center of Grand Prairie & Arlington has not responded to your online request within 24 business hours, please contact the clinic by phone at 972-206-2940.
COMPLETION OF THE FORM BELOW DOES NOT GUARANTEE AN AUTOMATIC RECEIPT OF MEDICAL RECORDS. VALIDATION OF IDENTIFICATION IS NECESSARY PRIOR TO RELEASING THE INFORMATION. ALL FIELDS ARE MANDATORY.
(check box) I agree to the terms and conditions as outlined above.
The personal health information contained in this fax is highly confidential. It is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to the patient. Any other use is in violation of the Federal Law Health Insurance Portability and Accountability Act (HIPAA) and will be reported as such. I understand that you will provide this information within 15 days from receipt of request and that t fee for preparing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.
For questions about medical records, please call 972-206-2904 EXT 208
__________________________________________________________________ PACGPA USE ONLY:
Date request received: _________ PACGPA staff Initials: __________
Contacted requestor: ______ Date of Contact:_________
Verified Identification: _______ Picture ID Attached? _________
Date records sent: __________ Confirmation received: __________
Fee needed? _________ Paid? ________ Receipt ID (if applicable)______
COMPLETION OF THE FORM BELOW DOES NOT GUARANTEE AN AUTOMATIC RECEIPT OF MEDICAL RECORDS. VALIDATION OF IDENTIFICATION IS NECESSARY PRIOR TO RELEASING THE INFORMATION. ALL FIELDS ARE MANDATORY.
(check box) I agree to the terms and conditions as outlined above.
The personal health information contained in this fax is highly confidential. It is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to the patient. Any other use is in violation of the Federal Law Health Insurance Portability and Accountability Act (HIPAA) and will be reported as such. I understand that you will provide this information within 15 days from receipt of request and that t fee for preparing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.
For questions about medical records, please call 972-206-2904 EXT 208
__________________________________________________________________ PACGPA USE ONLY:
Date request received: _________ PACGPA staff Initials: __________
Contacted requestor: ______ Date of Contact:_________
Verified Identification: _______ Picture ID Attached? _________
Date records sent: __________ Confirmation received: __________
Fee needed? _________ Paid? ________ Receipt ID (if applicable)______
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