MEDICAL RECORDS REQUEST FORM

I have requested a summary of the medical records for my children:

Name:

Date of Birth:

Please select one of the following:

Send record electronically through passport with no charge. Send record electronically via email, fax, or exported to a CD for $30 per patient. Paper copy of medical summary for $30 per patient. If I prefer the entire medical record there will be an additional charge of $0.50 per page.

Forwarding Address:

Email Address

Permanent Cell Number:

Reason for Requesting Records:

We request that your credit card information be on file with us to process any outstanding balances on your account. Our billing specialist will notify you before any transaction and will mail a receipt to your billing address.

Name on card:

Card Number:

Expiration Date:

Security Code:

Card Type:

Visa Mastercard Discover

Billing address for statements:

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.

Name of person requesting:

Relation to patient:

Date field

Office Use Only

Outstanding Patient Balance:

Outstanding Insurance Balance:

Date Payment Collected:

Please select:

CA CC CK

Date Patient Pick Up:

Your information will be encrypted.