FORMS

Click the link below to download our Privacy Policy.

HIPAA PRIVACY NOTICE

At our office, you will be asked to sign a document stating you have received the above document. If you would like to print it to fill out at home and bring it with you, you may do so by clicking the link below.

HIPAA PRIVACY ACKNOWLEDGEMENT FORM

Should you need to request records, either to be sent to our office or to another office from our office, please download and fill in the form below.

RECORDS REQUEST FORM

Instructions for Records Release Form

  • Please fill out complete form.
  • Middle section: Under “I Authorize the Following to Disclose…” place the information of the practice you are transferring records from. Under “Who Can Receive and Use…” place the information of the practice you are transferring records to. Our address is Wonder Kids Pediatrics, 20818 Gathering Oak, Suite 109, San Antonio, TX 78258.
  • Reason for Disclosure: check “Treatment/Continuing Medical Care”
  • Information to be Disclosed: check “All Health” for full records or “Other: Immunizations” for only vaccine records.
  • Note: some offices may take 2-4 weeks to return full medical records. *You may return this to us via mail, fax, email, or in person during office hours.