213 Greenhill Ave. Wilmington, DE 19805
(302) 429-5870
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Family Medicine at Greenhill Office Medical Records Transfer Request Form

I hereby authorize and request that you transfer a copy of all records in your possession concerning any diagnosis, prognosis and recommendation, as well as other data pertinent to your treatment of the patient named below.

Date of Birth
Patient Address
Practice Address

To: Family Medicine at Greenhill
213 Greenhill Avenue, Suite B
Wilmington DE 19805
Office Phone: 302-429-5870
Office Fax: 302-429-9284

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.