Medical Records Request

Continuation of Care

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TO THE RECORDS DEPARTMENT

FACILITY / PRACTICE

DATE OF REQUEST

ATTENTION

FAX / SECURE EMAIL

PATIENT INFORMATION

PATIENT FULL NAME

DATE OF BIRTH

PREVIOUS / OTHER NAME

DATES OF SERVICE

RECORDS REQUESTED

Complete medical record

Pathology reports

Office / procedure notes

Clinical photographs

Lab / diagnostic results

Other (describe below)

SPECIFIC DATES, DIAGNOSES, OR RECORDS NEEDED

PLEASE SEND RECORDS TO

REQUESTING PROVIDER

CLINIC / LOCATION

FAX

SECURE EMAIL

CONTACT NAME / PHONE

CONTINUATION OF CARE

These records are requested for treatment and continuation of care. Under the HIPAA Privacy Rule, a covered health care provider may disclose protected health information to another provider for treatment purposes without the patient's written authorization (45 CFR 164.506). Please use a secure delivery method. If your office requires additional documentation, please contact us.

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