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.
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.
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.
Email
example@example.com
Purpose of Transfer
Reason for Transfer
Records to Be Transferred
Complete Medical RecordOther
Method of Transfer
Secure Electronic Transfer (Preferred)FaxPostal MailSecure Online Portal (if applicable)
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