• Medical Records Transfer Authorization Form

    Medical Records Transfer Authorization Form

  • I,         , authorize transfer of medical records for the child/children named below:

  • Child #1 Name:  , DOB:  , My Relationship:     

    • Click here if other children in your family need medical records transferred to us from the same prior medical practice. You can add up to 5 additional children on this form. Or click Next below if you are transferring only one child. 
    • Child #2 Name:   , DOB:  , My Relationship:     

    • Child #3 Name:  , DOB:  , My Relationship:     

    • Child #4 Name:  , DOB:  , My Relationship:     

    • Child #5 Name:  , DOB:  , My Relationship:    

    • Child #6 Name:  , DOB: , My Relationship:     

    • Selection Close 
  • Where are you transferring from?

    To transfer records from Childhood Health Associates of Salem, simply select the first button beloe. To request records from another practice select the second button and enter the practice name, address and fax number (if known) below
  • TO:  

    Small Town Pediatrics, LLC  607 Welch St  Silverton, OR 97381

  • Request for Records

  • For each person listed above, please release the complete medical records, including all chart notes, immunization records, medication treatment history, notes from hospitalizations, specialists and other referral services, etc.

  • By my electronic signature below, I request electronic file transfer of medical records as instructed by Small Town Pediatrics.   By law, transfer must be completed within 30 calendar days of receipt.

    I understand I may revoke this authorization at any time, but that it remains valid unless/until revoked in writing.

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  • Please provide contact information to help us follow up with you as needed.

  • Should be Empty: