Medical Records Transfer Request Form

Medical Records Transfer Request Form

Please list all children for whom you'd like records transferred. If you have more than 4 children, please fill out a second form.
Patient Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Family Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Family Email Address*
example@example.com
Family Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To which office are you transferring records:
Office name and fax or address:
Informed Consent for Release of Confidential Information.
I understand that I may revoke this consent in writing at any time except to the extent action has already been taken.
I understand that this consent will expire 90 days after the date of my signature unless otherwise specified.
I understand that this information may include HIV/AIDS, mental health and chemical
dependency diagnosis, treatment, and test results.
I understand that the information released is for the specific purpose stated above.
Signature to confirm understanding of above Informed Consent*

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Name of Record Requester *

First NameLast Name
ParentLegal guardianSelf (>18 yrs old)
Should be Empty: