Medical Records Transfer Request Form printable pdf download

Medical Records Transfer Request Form

MEDICAL RECORDS TRANSFER

REQUEST FORM

3041 Churchill, Suite 500, Flower Mound, Texas 75022

Phone: 972-724-0500

Fax: 972-724-0501

MEDICAL RECORDS TRANSFER REQUEST FORM

I, ______________________________________________________, hereby authorize and request that you transfer a

copy of all records in your possession concerning any diagnosis, prognosis and recommendation, as well as other data

pertinent to your treatment of the patient named below.

PATIENT INFORMATION

Patient Full Name (Please Print):

Patient Address:

Social Security Number:

City:

Birthdate (mm/dd/yyyy):

State:

Zip:

Home Phone Number:

TRANSFERRING PARTY

Authorized Recipient’s Name:

Mailing Address (Line 1):

State:

Zip:

Mailing Address (Line 2):

Country

City:

Phone Number:

RECIPIENT

Jocelyn B. Dunham, MD, PA

3700 Forums Drive

Suite 200

Flower Mound, TX 75028

____________________________________________________________

Patient/Guardian Signature

____________________________________________________________

Date

Medical Records Transfer Request Form | v.11-0414

Medical Records Transfer Request Form