Transfer of Medical Records Form

Transfer of Medical Records Form
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*

Area CodePhone Number
Email Address

Confirmation Emailexample@email.com
Current Healthcare Provider
Practice Name/Healthcare Facility*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number

Area CodePhone Number
Practice Fax Number (if known)

Area CodePhone Number
Recipient - PIONEER VALLEY ALLERGY

212 Southampton Rd. Unit B Westfield, MA 01085
Fax Number

Area CodePhone Number
Email
example@example.com
Purpose of Request
Transfer of care
Records to Be Transferred

Last (2) office visits, skin testing (or relevant labs), ITX historyComplete Medical RecordOther
Method of Transfer

Secure Electronic Transfer (Preferred)FaxEmail
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*

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Patient Information