Medical Transfer Request Form

Dr. Judy Goldstein Pediatrics LLC

Please correct the errors described below.

Record Transfer Request

PLEASE BE AWARE THAT IT TAKES ABOUT 10 DAYS TO BE COMPLETED.

WHOLE CHART TRANSFERS ARE BEST NEEDED IF YOUR CHILD HAS ANY MEDICAL CONDITIONS.

Record transfer payment

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

** Charts vary in size and their number of pages. If your initial request was for the entire chart, you will be responsible for the payment of $.75 per page. A summary at no charge is no longer an option after the chart has been completed.

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

Your information will be encrypted.

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