Medical Records Release Request Form
ADVERTISEMENT
1VIRGINIA PEDIATRIC GROUP, LTD
I HEREBY REQUEST A COPY OF MEDICAL RECORDS FOR:
________________________________________________________________________________________________________
PATIENT NAME
DATE OF BIRTH
________________________________________________________________________________________________________
PATIENT NAME
DATE OF BIRTH
________________________________________________________________________________________________________
PATIENT NAME
DATE OF BIRTH
PLEASE SEND MEDICAL RECORDS TO / FROM:
___ FAIRFAX OFFICE
___ HERNDON OFFICE
___ GREAT FALLS OFFICE
___SOUTH RIDING OFFICE
3020 HAMAKER CT
131 ELDEN STREET
737 WALKER ROAD
25055 RIDING PLAZA
SUITE 200
SUITE 312
SUITE 4
SUITE 290
FAIRFAX, VA 22031
HERNDON, VA 20170
GREAT FALLS, VA 22066
SOUTH RIDING, VA 20152
REASON FOR TRANSFER:
Relocation
Change of Insurance
Other: ____________________________
__________________________________
____________________________
_____________
SIGNATURE OF RESPONSIBLE PARTY
RELATIONSHIP TO PATIENT
DATE
__________________________________________
________________________________________________________
CURRENT PHONE NUMBER OF RESPONSIBLE PARTY
EMAIL ADDRESS
FEE:
EMAIL: $25.00/CHART
COMPACT DISC: $30.00/CHART via USPS First-Class mail
_____________________________________
_______________
CREDIT CARD NUMBER
EXPIRATION DATE
_____________________________________________
________________________________________________
NAME ON CARD
ADDRESS OF CARD HOLDER
_____________________________________________
______________________
SIGNATURE OF CARD HOLDER
DATE
For VAPG use only:
Balance?
Checked by:
Date:
AR Paid:
MRT Paid:
Records E-mailed to:
By:
Date:
Records Mailed to:
By:
Date:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal