There is a fee of $15 for charts less than 50 pages, and $25 for charts bigger than 50 pages for the cost of supplies for and labor of copying, as well as storage for the requested information. Postage will be charged on an individual basis. An additional fee of $15 will be added for rush requests inside the allowed 15 day processing. Outstanding bills are due immediately with a forwarding address. Non-reconciled accounts are subject to collections 30-days following records transfer. Use of services and facilities after 30-day grace period are considered unauthorized and patients will be billed per usage. Records requests are handled pursuant to federal and state regulations, including Virginia code 32.1-127.1:03
Please call office to pay above fees
Please forward all records to the following address: (Please print clearly)
I understand that I am responsible for providing correct and legible information. Should I choose not to have these records sent directly to another doctor’s office, I understand that per Union Mill Pediatrics’ Policy, I must make or decline an appointment to review them in the office prior to taking them, and further agree accept complete responsibility for the safe keeping of the records I take.
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Individual 18+, Parent or Legal Guardian
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