Record Release/Transfer

DATE:

Add patient information

I AUTHORIZE:

(Name of the Provider/ Person or Facility):

RELEASE MY MEDICAL RECORDS TO

(Name of the Provider/ Person or Facility):

CHARGES:

Vaccine records ONLY (no charge)

Entire Medical Record (Paper version) $22.88 fee and .76 cents for each page

Entire Medical Record (Email Version) $22.88 fee

Email address

Entire Medical Record (Faxed Version) $22.88 fee

Fax Number:

REASON FOR REQUEST:

Transfer to a new Doctor

Moving

Lawyer request

Personal use

I understand that there is a copy fee (explained above) per chart, the records must be picked up in person and it will be ready for pick up in 2 to 3 weeks after we have received payment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Parent/ Guardian/ Patient Name

Parent/ Guardian/ Patient Name (Signature)

Your information will be encrypted.