Transfer of Medical Records Form

Transfer of Medical Records Form
Patient Information
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Current Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Healthcare Provider (Sender)
Healthcare Facility/Hospital
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
New Healthcare Provider (Recipient)
Healthcare Facility/Hospital
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Purpose of Transfer
Reason for Transfer
Records to Be Transferred
Other
Method of Transfer
Additional Instructions or Comments
Date of Transfer
MonthDayYear
Date
Patient/Legal Representative Consent:
I have read and understood this authorization for the transfer of medical records and voluntarily consent to its terms.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Patient Information