Medical Records Transfer Out of PANF

Medical Records Transfer Form

(for established patients leaving our practice)

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

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

122 Grove Street, Suite 203, Franklin, MA 02038

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

Date of Request:*

Patient's Name:*

First NameLast Name

Date of Birth:*

Best Number:*

Area CodePhone 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 areaTransferring to adult primary careOther

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).

PayPal Mailing Fee (Enter 15.00)

USDDescription

Note: When you hit submit, the form will take you to our PayPal page to complete payment. The PayPal page will ask you for a "donation". The donation format is the only one offered by the online form that will allow our patients to pay for records online. You are not actually making a donation to our practice.

Please send records to:

Doctor, Office Name, or Patient Address

Address

City:

State:

Zip Code:

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, venereal 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*

Relationship to patient

Please click the submit button to send to our office electronically

OR

print this form and bring it into the office.