Wolfchiropractic.net - Request for Records

Records Transfer Request
To:
Date:

MonthDayYear
Date
Phone:
Please enter a valid phone number.
Fax:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I herby authorize the release of my “Protected Health Information” or copies of such and request that they be transferred to the named office/facility below.

X-rays: (FAX REPORT& MAIL IMAGES), Date Range: Date
- Cervical
- Thoracic
- Lumbar
- Extremity
MRI/CAT (FAX REPORT ONLY), Date Range: Date
Lab/Blood work: , Date Range: Date
Treatment/Office Notes:  , Date Range: Date
To be sent OR faxed to:

Dr. Jeanine Wolf-Richter FAX: 253-838-0505
Wolf Chiropractic Center, PS Inc.
622 South 320th Street, Ste. B
Federal Way, WA 98003
Name of patient:
DOB:

MonthDayYear
Date
Signature of patient/parent/guardian:

Clear
PROHIBITION OF REDISCLOSURE: The information in this facsimile is intended only for the use of the individual or entity named above. This transmission may contain information that is privileged, confidential and/or otherwise exempt from disclosure under applicable law. You are prohibited from making any further disclosure of this information except with the specific written consent of the person to whom it pertains.

NOTICE TO UNINTENDED RECIPIENT: In the event you have erroneously received this transmittal, please be advised that the accompanying material constitutes confidential information protected by laws. Please contact the sender of the FAX at eth number above immediately upon receipt. Your cooperation is appreciated.
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Records Transfer Request