REQUEST FOR MEDICAL RECORDS TO BE TRANSFERRED 2026

1. Click ‘Get Form’ to open the REQUEST FOR MEDICAL RECORDS TO BE TRANSFERRED in our editor.
2. Begin by filling out the PATIENT INFORMATION section. Enter your NAME, DATE OF BIRTH, and SSN. Ensure that your STREET ADDRESS, CITY, STATE, ZIP, PHONE, and EMAIL are accurately provided.
3. In the REQUEST FOR MEDICAL RECORDS TO BE TRANSFERRED section, indicate whether you are requesting records TO/FROM a Health Care Facility, Physician, Self, Lawyer, Disability Company, or Other by circling the appropriate option.
4. Complete the NAME and ADDRESS fields for the recipient of the medical records. Include CITY, STATE, ZIP, PHONE, and FAX # if applicable.
5. Select which types of medical records you wish to transfer by checking the relevant boxes such as COMPLETE MEDICAL RECORD, MRI REPORTS, OFFICE NOTES, etc.
6. Specify the date range for the records requested by filling in either specific dates or selecting 'ALL TIME'.
7. Finally, sign and date the form in the designated area to authorize the request.

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