Patient Transfer Form In

Prospect Pediatrics P.S.C.
9217 U.S. Highway 42 Prospect, KY 40059 (502)228-1312
Terence P. McKenna, MD., F.A.A.P.
Patrick Hynes, M.D., F.A.A.P.
Pamela C. Biddle, M.D., F.A.A.P.
Deborah Massey, M.D., F.A.A.P.

Request for release of medical records

I hereby request that my children's medical and confidential records be released to Prospect Pediatrics:

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Released To

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                           Physician's Name

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                           Mailing Address

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                       Child's Name / Parent Name

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                           Child's Address

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                         Parent's Signature

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       Phone                                          Date