Professional Request for Medical Records

Washington Area Clinical Center

2905 Mitchellville Road Suite 204 Bowie, MD 20716 Phone: 301-701-6965 Fax: 240-293-4731 records@waccenter.com www.waccenter.com
Name of Patient Whose Records are being requested*

First NameMiddle NameLast Name
Date of Birth of Patient*

MonthDayYear
Date
Secure Email To Send Records
Secure Fax *

Area CodePhone Number
Name of Requestor or Clinician*

First NameLast Name
Professional Office or Affiliation*
Requestor Phone Number*

Area CodePhone Number
Address (If records shall be mailed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records Being Requested
Complete Chart Record (does not include billing information or radiographic images) Visit /Encounter Notes (If yes, specify dates or date range)
Treatment Plan Attendance History Medication List Treatment Summary
Date Range
Purpose of Records Request

Personal Request (Patient would like records)Transfer of careConcurrent/collaborative careContinuation of CareLegalInsurance RequestOther
Special Authoriztions

HIV / AIDSSexually Transmitted DiseasesTransfer of careConcurrent or collaborative careMental Health CareSubstance AbuseOther
Patient Release of Information

Browse Files

Cancelof
Please note: A release of information but be accompanied by this request. Our clinic requires a release to be signed by the patient both from the requesting office and internally with our clinic.
Requestor Email*
example@example.com
Should be Empty:

Washington Area Clinical Center