Medical Records Release Request to PANF

(for new patients coming to 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

Address *

Multi-line address

Country/Region

Address

City

Zip / Postal code

Best Phone Number:

Please send records to:

Location:

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

122 Grove Street, Suite 202, Franklin, MA 02038

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 I have entered is, to the best of my knowledge, correct.

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

Signature

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Sign or type your signature

Relationship to patient

Step 1. Please print this form (right click and print) and forward it to your previous doctor.

Thank you!

115 Norwood Park South Suite 110, Norwood, MA 02062

781-769-4090 or 508-528-5404

Medical Records Release Request to PANF

Pediatric Associates