Transfer of Medical Records Form

Transfer of Medical Records Form

Please fill out the form below to request your medical records. Your most recent appointment note can be requested free of charge, which includes history, diagnosis and medication history. Any additional records will be charged at $1.25 per encounter. Records will be received through our secure online portal, or if you are requesting records to be mailed, there will be a $9.00 preparation fee, with an additional $6.95 for certified mail.
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Record Recipient
I am requesting my records from date of service

MonthDayYear
Date
To date of service

MonthDayYear
Date
Most recent visit note only
Recipient*
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number. Required for all third party recipients.
Purpose of Transfer
Reason for Transfer*
Records to Be Transferred*

All Behavioral RecordsDischarge NotesMedical ConsultationsProgress NotesFinancial RecordsMedical History & Physical ExamsLaboratory & Pathology ReportsPsychological TestsOther (List below in Additional Instructions or Comments)
Method of Transfer ($1.25 per encounter)*

FaxPostal Mail ($9.00 preparation fee)Certified Mail ($9.00 preparation fee, with an additional $6.95 for certified mail)Secure Online Portal
Additional Instructions or Comments
Patient/Legal Representative Consent:

I have read and understood this authorization for the transfer of medical records and voluntarily consent to its terms.
Date

MonthDayYear
Date
Signature*

Clear
If you are requesting your own records they will be sent by secure message through our Patient Portal. If help logging into the portal is needed, please reach out to our main line at 928-985-1495. If you are requesting your records to be sent to a third party agency they will be sent by fax or mailed. Expect this process to take up to 30 days for approval and processing. Requests are completed in the order they are received and the complexity of the records being requested will affect the time it takes for your request to be processed. We are grateful for your understanding and patience.
Should be Empty:

Transfer of Medical Records Form

Patient Information

Record Recipient

Purpose of Transfer