Medical Records Transfer Request Form

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

Patient Information:

Patient Name

First

Middle

Last

Patient's Date of Birth:

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient Phone

Transferring Party:

Facility Name

Faciltiy Address

Address Line 1

Address Line 2

City

State

Zip Code

Facility Phone

RECIPIENT:

Children's Psychiatric Services of South Texas

5440 Old Brownsville Rd.
Corpus Christi, TX 78417

Agree

I AGREE

By selecting the “I AGREE” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email.

Patient/Guardian Electronic Signature

Parent's/Guardian's Date of Birth

Today's Date