Authorization to Release Information #

This Authorization Release Out form to release medical information and/or records from Adirondack Internal Medicine & Pediatrics, PC to another provider.  This form can also be used to authorize an individual or individuals to discuss your medical care.

If you need to have records sent to our office from another provider, we have posted a special version of the medical release form for that purpose, pre-populated with our contact information.  To download this alternate version of the medical release form, down the Authorization Release In form below.  To expedite processing, you will want to send this form directly to the provider from whom we will receive your records.

If you have questions about how to complete your release form, or about which form to use, please call us at 518-891-3845.

Authorization Release Out

Authorization Release In

Health Care Proxy #

The New York State Health Care proxy law allows you to appoint someone you trust--for example, a family member or close friend--to make health care decisions for you if you lose the ability to make decisions yourself.  The form you would fill out to appoint a Health Care Proxy, and its accompanying instructions, are posted below as separate documents.

Health Care Proxy Instructions

Health Care Proxy Form Aimp

Consent by Proxy for Non-Urgent Pediatric Care #

This is a form to designate a proxy decision maker for non-urgent pediatric care decisions.

Consent By Proxy For Non Urgent Care

Blood Pressure Log #

This document is a helpful tool that allows you to easily log your blood pressure readings.

Blood Pressure Log Form

Blood Glucose Journal #

This document is a helpful tool that allows you to easily log your blood glucose level.

Blood Glucose Journal Form

Medical Dosing #

The Pediatric Diphenhydramine Dosing (Children's Benadryl) form explains the proper dosing for Pediatric Diphenhydramine (Children's Benadryl), in a chart organized by patient weight.

This Ibuprofen (Motrin) Pediatric Dosing form explains the proper pediatric dosing for Ibuprofen (Motrin), in a chart organized by patient weight.

The Pediatric Acetaminophen Dosing (Children's Tylenol) form explains the proper dosing for Pediatric Acetaminophen (Children's Tylenol), in a chart organized by patient weight.

Pediatric Benadryl Dosing

Pediatric Motrin Dosing

Pediatric Tylenol Dosing