Upload/Email Your Forms

How to upload a child’s form: 

Step 1: Fill out the Electronic Consent Form below. We cannot start processing your child’s form until this is completed. This form only needs to be completed once for each child, not once for each form. If you have already filled out this form for your child, proceed to step 2, click here.

REQUEST FOR CONFIDENTIAL ELECTRONIC COMMUNICATIONS - ELECTRONIC CONSENT FORM

Patient First Name*:
Patient Last Name*:
Patient Date of Birth*: (mm/dd/yyyy)
Date of Request*: 8/19/2018

On the website, there is now an option to submit your forms to Peachtree Park Pediatrics electronically. Under forms and handouts, there is a tab called “Upload/Email Your Forms.” From here, your forms will be delivered to Peachtree Park Pediatrics via a non-secure email. This means that the email is not secure and may create a risk of improper disclosure to unauthorized individuals. If you still choose to send us your forms on the website, you are stating that you are willing to accept that risk, and will not hold the practice responsible should any improper disclosure occur. In an effort to mitigate the risk of improper disclosure, Peachtree Park Pediatrics will not email your completed forms back to you.

Electronically submitted forms will still take approximately 3 business days to be processed, and you may ONLY send documents for your physician and forms that need to be filled out for school/camp/etc. You also will still need to pay your annual forms fee before your forms will be processed. Peachtree Park Pediatrics will not respond to medical advice questions or prescription refills through the webpage or email.

Your signature below will indicate that, should you email us forms, you agree to the above terms. This agreement shall remain in effect until terminated by parent/patient via written request.

Acknowledgement and Agreements:

I understand and agree that I have the option to electronically submit forms. If I choose to electronically submit forms, that method of communication is not secure, making my PHI at risk for receipt by unauthorized individuals. If I choose to electronically submit forms, I accept the risk and will not retaliate against the practice in any way should this occur.

Signed*:    Date*: (mm/dd/yyyy)
Phone*:
Street Address*:
City*:   State*:   Zip Code*:
Security Code: security code
Enter Security Code*: