Release of Medical Records

Please correct the errors described below.

To increase safety and to reduce contact, we are asking you to request electronic copies of your records or send records to us via email. You can email all incoming records to ROIRequests@4securemail.com. Thank you

Pediatric and Adolescent Medicine
1190 Baker Street, Suite #103
Costa Mesa, CA 92626
949.999.8106 FAX or
ROIRequests@4securemail.com

Please release medical records on the following patient(s): Including but not limited to immunizations, office notes, growth charts, consult letters, labs, and procedure results.

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 or Legal Guardian if patient is under age 18)

Please NOTE: We do not charge a fee for one-time transfer of medical records to a physician, or for a parent’s request for 1-2 pages from the chart. $30 flat rate charge for records produced as a multi-page PDF on a CDR, or for a full set of records requested because of outdated technology. A small number of copies can be requested at an additional rate of 0.25 per page. All requests will be processed by Integrated Business Solutions and payment to be made payable to them.

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.

Revised 4.17.2024

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