Forms

Due to Health Insurance Portability and Accountability Act (HIPAA) regulations, only parents or legal guardians can request records; once your child turns 18, they can authorize access independently.  To initiate a Clinical Form Request or a Medical Record Request, please complete the appropriate form.

You may submit the completed request via the fax number listed on the form or drop off at one of our office locations.  Many forms require the information to be based on an examination completed within 12 months of the date the form is completed or may require specific evaluations that were not performed at the routine physical, i.e. sport vitals, asthma/allergy treatment plans.  An additional office visit may be required.

Pick-up of Clinical Forms or Medical Records must be in person at our office with proper ID. If you prefer mailing, we will mail the forms to the home address on file at your request. Please provide us with a stamped and self-addressed envelope for this purpose.

Fees are collected at the time our practice receives the request.  Our front staff does not have the authority to waive or reduce fees.

Clinical Forms Fees:

• No charge for forms submitted during Well Child Exams
• $10 per form requested outside of a Well Child Exam
• $25 charge for FMLA forms

Medical Records Fees:

• No charge for the initial Third-Party Requests such as a new provider, new practice, specialist, hospital, insurance company, etc.
• Request for Records for Patient’s Personal Use is a $10.00 flat fee plus $.50 per page up to fifty pages then $.25 for pages fifty-one and above
• Our team aims to process requests within 14 business days. Please note that older records may require more time, as they are stored offsite.