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Medical Records Request Form

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Medical Records Request Form Page 2
Medical Records Request Form
site at the Practice. If the Practice is unable to comply with my approved request within
the applicable time limit, it may extend the applicable deadline for up to thirty (30) days
by notifying me in writing.
I would prefer to: pick-up or view the Requested Information at a mutually agreeable
time and place; have a copy of the Requested Information mailed to me at the
following address:
I understand that the Practice will charge me [$0.75] per page for copying fees
and that there may be an additional fee for clerical work necessary to complete my
request, as well as any applicable mailing fees. If I am granted access to the Requested
Information, I [please check the appropriate boxes]
would would not like the Practice to provide me with an additional written
summary explanation of such Requested Information at an additional cost to me of
[$_____].
____________________________________________ __________________
Signature of Patient (or Personal Representative) Date
____________________________________________
Printed name of Personal Representative Relationship to
Patient
* * * * *
After you have completed this form please return it to our office:
Murray Hill Medical Group, P.C.
317 East 34
th
Street
ATTN:The name of your specific Doctor”
New York, NY 10016
You may also fax it directly to your physicians office.
Medical Records Request Form
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