Medical Record Release Form

Phillip M. Renick, MD, FAAP
Paula Max-Wright, MD, FAAP
Amanda Gerber, MD
BLUESTONE PEDIATRICS PLC
OUTGOING MEDICAL RECORDS RELEASE FORM
RELEASE FROM:
RELEASE TO:
____________________________
Physician/Clinic’s Name
____________________________
Address
____________________________
City
State
Zip
BLUESTONE PEDIATRICS
4059 Quarles Court
Harrisonburg, VA 22801
Phone (540) 437-4800
Fax (540) 437-9012
Please release medical records on the following patient(s):
1. ______________________________________
Date of Birth: ________________
2. ______________________________________
Date of Birth: ________________
3. ______________________________________
Date of Birth: ________________
4. ______________________________________
Date of Birth: ________________
Reason for Transfer: ___________________________________________________________
_____________________________________________________________________________
Check one:
records to be picked up by parent
records to be mailed
($5 fee per chart to mail)
other (specify)
__________
*Depending on the number of pages requested a fee may be applied
Forwarding address: ___________________________________________________________
City ____________________ State _____________ Zip ____________
By signing below, I acknowledge that my request for transferring records certifies the patient
name(s) listed above will no longer be patients at Bluestone Pediatrics.
Print Parent’s Name: ___________________________________________________________
Signature: ________________________________________
Date: __________________
For Office Use Only
Chart # ______
Release form completed correctly and signed
Status changed in computer
Records copied and sent or picked up
Fee billed/copied to LIA
Chart moved to inactive
Initials & Date
____________
____________
____________
____________
____________