Medical Records Request Form (Page 2 of 2) in pdf

Medical Records Request Form Page 2

site at the Practice. If the Practice is unable to comply with my approved request within

the applicable time limit, it may extend the applicable deadline for up to thirty (30) days

by notifying me in writing.

I would prefer to:

pick-up or view the Requested Information at a mutually agreeable

time and place;

have a copy of the Requested Information mailed to me at the

following address:

I understand that the Practice will charge me [$0.75] per page for copying fees

and that there may be an additional fee for clerical work necessary to complete my

request, as well as any applicable mailing fees. If I am granted access to the Requested

Information, I [please check the appropriate boxes]

would

would not like the Practice to provide me with an additional written

summary

explanation of such Requested Information at an additional cost to me of

[$_____].

____________________________________________

__________________

Signature of Patient (or Personal Representative)

Date

____________________________________________

Printed name of Personal Representative

Relationship to

Patient

* * * * *

After you have completed this form please return it to our office:

Murray Hill Medical Group, P.C.

317 East 34

Street

ATTN: “ The name of your specific Doctor”

New York, NY 10016

You may also fax it directly to your physicians office.

Medical Records Request Form Page 2