Medical Records Transfer From PANF

(for established patients leaving our practice)

Pediatric Associates

115 Norwood Park South, Suite 110, Norwood, MA 02062

(p): 781-769-4090, Fax: 781-769-6485

122 Grove Street, Suite 202, Street, Franklin, MA 02038

(p): 508-528-5404, Fax: 508-528-5383

Date of Request

Patient's Name:*

First name

Last name

Date of Birth

Month

Day

Year

Best Number:

Please note: if you would like us to mail your records, there is a $15 shipping charge. You may call our office to make this payment over the phone, or use the PayPal widget below.

You may pick up your records in our office free of charge.

We cannot fax your medical record.

If you would like your records to be mailed your new doctor, please fill out the address information below, and call our office or use the PayPal widget below to submit the $15.

If you are going to pick up your records in our office, you may leave the address information below blank.

Reason for transferring out of practice:

Moving out of area

Transferring to adult primary care

Other

Select Option:

I would like to pick up my records in the Norwood Office.

I would like to pick up my records in the Franklin Office.

I am a Norwood patient, and I would like my records to be mailed to the address below. I understand I must pay the $15 fee. (Please fill out address information below).

I am a Franklin patient, and I would like my records to the address below. I understand I must pay the $15 fee. (Please fill out address information below).

Other

PayPal Mailing Fee (Enter 15.00)

Please send records to:

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Location:

115 Norwood Park South, Suite 110, Norwood, MA 02062

122 Grove Street, Suite 202, Franklin, MA 02038

Notes/Comments:

If applicable, please also include my HIV (AIDS) testing/treatment information with this release.

I agree to release information regarding drug and/or alcohol abuse, psychiatric care, vereal disease, social service, hepatitis B testing/treatment and/or any other sensitive information.

By signing below, I indicate that I have read and understand all the information on this form. Any information that I have entered is, to the best of my ability, correct.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Sign or type your signature

Relationship to patient

Please click the submit button to send to our office electronically

OR

print this form and bring it into the office.

I understand that the information submitted may include personal health information and consent to its secure storage and use.

115 Norwood Park South Suite 110, Norwood, MA 02062

781-769-4090 or 508-528-5404

Medical Records Transfer From PANF

Pediatric Associates