Transfer Records/ Copy of Records Form

First Name: *

Last Name: *

Date of Birth: *

Person Making Request: *

Relation to Patient: *

Address: *

Street: *

City: *

State: *

Zip Code: *

Phone Number: *

Reason for Request: *

There is a charge of $0.76 per page. If mailed, postage will be an additional charge. Payment must be made before any copies are picked up/mailed out/sent through fax. For your convenience, we accept cash, check, credit card and debit card. (Discover/MastercardVisa/AMEX).

How would you like your records delivered?

Fax Attention to: *

Mail Attention to: *

Fax Number: *

Address: *

Transfer Records/ Copy of Records Form

Email Address: *

Please note if you choose your medical records to be e-mailed at the above email, you understand your information is not 100% safe/protected, per HIPAA guidelines. Our e-mail is not encrypted; therefore, your information is not fully protected. By choosing your medical records to be e-mailed, Physicians Now, LLC will not assume responsibility nor liability for any information that is exposed. Physicians Now, LLC strongly recommends to stay within the HIPAA guidelines. Which is by picking up, faxing or mailing medical records.

I agree and understand the above e-mail disclaimer. By signing this I will not hold Physicians Now, LLC responsible for any HIPAA violations.

Patient/Guardian Signature: *

Use your mouse or finger to sign in the box below.

Date: *

Office use only:

Copy of records Charge:

Notified of Transfer of record's fee and any previous outstanding balance.

Previous Balance:

Total Due:

Spoke to:

Total Received:

Date:

Picked up:

Initial

Medical Records prepared by:

(Signature of person picking up)

Use your mouse or finger to sign in the box below.

Medical Records prepared by:

(CID : 9362)

Transfer Records/ Copy of Records Form

Transfer Records/ Copy of Records Form

Transfer Records/ Copy of Records Form

Transfer Records/ Copy of Records Form

Office use only:

Forms Sent!