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CHART TRANSFER REQUEST (please print legibly)Date: I hereby authorize Center City Pediatrics, LLC to release MEDICAL records to: Office Name: Address: City:State:Phone #: Zip:Fax #: For the following

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How to fill out chart transfer request

01

Step 1: Start by entering your personal details, such as your name, contact information, and date of birth, in the designated fields on the chart transfer request form.

02

Step 2: Indicate the reason for requesting the chart transfer. This could be due to changing healthcare providers, seeking a second opinion, or relocating to a different city or state.

03

Step 3: Provide information about your current healthcare provider, including their name, address, and contact details. This will help facilitate the smooth transfer of your medical records.

04

Step 4: Specify the healthcare provider or institution to which you want your chart to be transferred. Ensure you include their complete contact information for accurate delivery.

05

Step 5: If you have any preferences or specific instructions regarding the chart transfer, make sure to clearly communicate them on the form.

06

Step 6: Review the completed form for any errors or missing information. Ensure all details entered are accurate and up-to-date.

07

Step 7: Sign and date the chart transfer request form. Your signature confirms your consent for the transfer of your medical records.

08

Step 8: Submit the filled-out form to your current healthcare provider's medical records department, or follow their specified instructions for submission.

09

Step 9: Keep a copy of the chart transfer request form for your records. This will serve as proof of your request.

10

Step 10: Follow up with your current healthcare provider and the receiving healthcare provider to ensure that the chart transfer process is completed successfully.

Who needs chart transfer request?

01

Anyone who wishes to have their medical records transferred from one healthcare provider to another is required to fill out a chart transfer request. This could include individuals who have changed healthcare providers, are seeking a second opinion, or are relocating to a different city or state. Additionally, individuals who are transferring to a new hospital or medical institution may also need to request a chart transfer.

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What is chart transfer request?

Chart transfer request is a formal request to transfer medical records or information from one healthcare provider to another.

Who is required to file chart transfer request?

Patients or their authorized representatives are required to file chart transfer requests.

How to fill out chart transfer request?

To fill out a chart transfer request, patients need to provide their personal information, the healthcare provider information, and sign consent for the transfer.

What is the purpose of chart transfer request?

The purpose of a chart transfer request is to allow patients to move their medical records or information to a new healthcare provider for continuation of care.

What information must be reported on chart transfer request?

The chart transfer request must include patient's personal information, healthcare provider details, reason for transfer, and consent for transfer.

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