Medical Records Transfer Request Form | Family Medicine at Greenhill

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.

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Patient Name

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

From (Name of Practice)

Practice Address

Address Line 1

Address Line 2

City

State

Zip Code

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Office Phone Number

Office FAX Number

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

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Patient / Guardian Signature:

Date

Electronically Signed

I Accept

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.

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Main Office

213 Greenhill Avenue Suite B Wilmington, DE 19805
office@fmagreenhill.com
(302) 429-5870
Office Hours:
Monday–Thursday: 7:00am-7:00pm
Friday: 7:00 am-5:00 pm
Saturday: 8:00am-1:00pm
Walk-In (Monday–Friday) Greenhill Ave 4:00pm–5:00pm

Limestone Rd. Office

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