Medical Records Transfer Request

 

If you have been asked to arrange for records and your physician requires a signed release, please print and complete this form for each physician and facility such as a hospital or clinic.  Then fax or mail the form to that physician or facility so that we may obtain your child's medical records for review.

 

 

DATE: __________________

 

TO: _________________________________________(doctor, hospital, clinic)

 

ADDRESS: ______________________________________________

 

CITY: __________________________ STATE: ______ ZIP: ______

 

 

PATIENT: ______________________________________________

 

Date of Birth: ___________________________

 

I, the undersigned, do hereby authorize the release of all medical records belonging to the above patient, especially those relating to the patient’s past and present ear, nose, throat, hearing, speech-language, respiratory, and general head and neck problems, illnesses, and treatment thereof. Copies of records should be transferred either by mail, courier, and/or electronic facsimile to Howard G. Smith, M.D. at the above address. I understand that I am requesting the transfer of protected health information about my child and other family members.

SIGNED: _________________________________________

Relation to patient: _________________________________

DATE: ______________________

 

 

Please print and complete this form for each physician and facility such as a hospital or clinic.  Then fax or mail the form to that physician or facility so that we may obtain your child's medical records for review.

 

Next: Privacy Statement