Patient Record Request

Patient Name

ID #

Date of Birth

I, hereby request the following:

To view my record

To receive a paper copy of my record

To receive CD Rom of X-rays

Requests must be submitted in writing to Foot Health Center, LLC (Office of Dr. Michael Verdi, Dr. Douglas DeLorenzo, Dr. Merihan Botros, Dr. Kristen Discepola and Dr. Patricia Berran). If approved, an agreed upon date, time, and place will be scheduled. If the electronic form and format requested is not readily producible by Foot Health Center, LLC in such form and format requested, then Foot Health Center, LLC will provide a readable electronic form and format as agreed. A nominal fee may be charged for the labor of copying, whether in paper or electronic form, and supplies for creating a paper copy of the electronic media if requested on portable media. If the request is denied, the patient and/or patient representative will be informed as to the reason why.

Date

Time

Place

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.

Patient Signature

Date

Request Received By

Date

Your information will be encrypted.