Request for release of medical records to fpa

REQUEST FOR RELEASE OF MEDICAL RECORDS TO FPA
To:_____________________________________________________________________________

(Physician or Facility Name where records are currently)

__________________________________________________________________________________

(Address, City, State, Zip)

___________ _______________________________________________________________________

(Telephone)

I hereby authorize you to release medical records for:
_________________________________________________________________________________

(Patient Name(s))

_________________________________________________________________________________

(Date(s) of Birth)

Please mail records to:
Practice Name:____Family Practice Associates of West Grove________________________________
Physician Name:_____________________________________________________________________
Address:_________900 West Baltimore Pike, Suite 200_____________________________________
________________West Grove, PA 19390________________________________________________

Information needed: _______ All Records

__________________________________________________________ Date:__________________

(Patient/Parent/Guardian Signature(s))

__________________________________________________________ Date:__________________

(Patient/Parent/Guardian Signature(s))

900 West Baltimore Pike, Suite 200, West Grove, PA 19390 (Office) 610-869-4627 (Fax) 610-869-4628