MEDICAL RECORDS TRANSFER REQUEST FORM

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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

Last

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

I, the undersigned , agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.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.

Patient/Guardian Electronic Signature

Date

Patient Information

Transferring Party

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