Medical Records Request Form printable pdf download

Medical Records Request Form

Name of Medical Practice:

______________________________________________

Patient Name:

______________________________________________

DOB:

______________________________________________

Date Requested:

______________________________________________

Requested by:

Patient [ ] Other [ ]_____________________________

Delivery Method:

Mail [ ]

Address: ______________________________________

Fax [ ]

Number: ______________________________________

Pick Up [ ]

Please note:

All fees must be paid in full prior to our office sending out any medical records

Base Fee

$10.00

(from one to 14 pages)

From 15 to 25 pages ($0.75) $ 0.75 x _____ pages

$__________

From 26 to 99 pages ($0.50) $ 0.50 x _____ pages

$__________

100 or more pages ($0.25)

$ 0.25 x _____ pages

$__________

Total: $_______________

Harnett Health | PO Box 1706, Dunn NC 28335 | (910) 892-1000 |

Medical Records Request Form