Request for Release of Medical Records From FPA

FAMILY PRACTICE ASSOCIATES, P.C.

Please correct the errors described below.

Name

Date of Birth

Address

City/State/Zip

Date of Request

(Please allow up to 1 week for copying records.)

I hereby request that my medical records be released for dates of service

From

with the exception of:

Progress Notes

Drug or Alcohol Abuse

Psychological or Psychiatric Conditions

STDs / Communicable Diseases

Other

If other, please specify:

I understand this information will be used for:

Please send records to:

Practice Name and/or Provider Name

Address

City/State/Zip

Phone

Fax

We are happy to send medical records to a Medical Facility or Physician’s Office for NO CHARGE.

If patients are requesting medical records for personal use, our fees are as follows (please choose one):

$0 – 0-10 pages of medical records to be picked up or mailed

$15 – 11-150 pages of records to be picked up

$20 – 11-150 pages of records to be mailed

$25 – 151+ pages of records to be picked up

$30 – 151+ pages of records to be mailed

Please enclose check payable to Family Practice Associates OR charge to a credit card:

Name on card

Billing Address

Card #

Expiration

Security Code

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.

Signature

Date

Date mailed /Pick up:

Signature:

Type of ID presented:

Daytime Phone:

Your information will be encrypted.

Electronic signature

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