Phillip M. Renick, MD, FAAP Paula Max-Wright, MD, FAAP Amanda Gerber, MD BLUESTONE PEDIATRICS PLC OUTGOING MEDICAL RECORDS RELEASE FORM RELEASE FROM: RELEASE TO: ____________________________ Physician/Clinic’s Name ____________________________ Address ____________________________ City State Zip BLUESTONE PEDIATRICS 4059 Quarles Court Harrisonburg, VA 22801 Phone (540) 437-4800 Fax (540) 437-9012 Please release medical records on the following patient(s): 1. ______________________________________ Date of Birth: ________________ 2. ______________________________________ Date of Birth: ________________ 3. ______________________________________ Date of Birth: ________________ 4. ______________________________________ Date of Birth: ________________ Reason for Transfer: ___________________________________________________________ _____________________________________________________________________________ Check one: records to be picked up by parent records to be mailed ($5 fee per chart to mail) other (specify) __________ *Depending on the number of pages requested a fee may be applied Forwarding address: ___________________________________________________________ City ____________________ State _____________ Zip ____________ By signing below, I acknowledge that my request for transferring records certifies the patient name(s) listed above will no longer be patients at Bluestone Pediatrics. Print Parent’s Name: ___________________________________________________________ Signature: ________________________________________ Date: __________________ For Office Use Only Chart # ______ Release form completed correctly and signed Status changed in computer Records copied and sent or picked up Fee billed/copied to LIA Chart moved to inactive Initials & Date ____________ ____________ ____________ ____________ ____________