Records Request

I acknowledge that my Authorization for disclosure of Protected Health Information must be on file to fulfill this request

If you need the form it is available on our website under - New Patients https://www.arrowfamilymedicine.com/new-patients

Email us at office@arrowfamilymedicine.com with questions or to submit the form. *

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Patient Name *

Date of Birth * +

Your Email Address - So we can contact you with questions *

Are you requesting your full medical record or only specific records (i.e. labs, cardiology reports, mammogram, etc.)? *

What is the reason for the request? *

Are you transferring to another medical pratice? *

Yes

What is the name of the doctor or practice the records should be sent to? *

What is the address of the doctor's office? *

What is the phone number of the doctor's office? *

What is the Fax number of the doctors office? *

Would you like to come pick up your records? If you select no, records will be faxed to the doctor's office indicated above.

** If you opt to pick up your records, please email (or call) the office to be

certain your copy ready for pick up

Is there a specific date the records should be ready or sent by? (Requests are processed within two weeks of date received.) * +

Is there any additional information we should know about the request? *