Medical Records Request Form printable pdf download

Medical Records Request Form

Summergate Professional Center

27406 Cashford Circle

Wesley Chapel, FL 33544

Phone (813) 994-8900

Fax (855) 388-5350

Medical Records Request Form

Date of request ______________________

I, __________________________________, request Scotch Institute to make copies of

my medical records for my personal inspection. I understand that these records contain

protected health information. I agree to be responsible for the cost of copying these

records, including copying fees, labor, supplies, and postage (if applicable). The charge

for this will be $1.00 per page for the first 25 pages of written material and $0.25 for

each additional page. I agree to pay for this prior to the service being rendered.

Patient Printed Name __________________________________________

Date of Birth ________________________________________________

Please specify if you want to pick them up at our office or if you would like us to mail

them to you. If mailing, please note the address below, or if picking up please advise a

phone number where we can reach you when the copies are ready.

______________________________________________________________________

_____________________________________________________________________

______________________________________________________________________

_____________________________________________________________________

Patient Signature _____________________________________________

Medical Records Request Form