Medical Records

Medical Records Request Form

* Indicates required field

Person Served Name *

First

Last

Person Served Address: *

Date Of Birth ie: 01011960 *

Person Served Phone (numbers ONLY no dashes): *

Date of Documentation Request ie: 09262022 *

Person Served/Agency Making the Request *

Telephone Number of Person Requesting Medical Records: (numbers ONLY no dashes) *

Address Mailing the Request To: *

Documents Requested: *

Assessment/Evaluations Treatment Plans Discharge Summaries Other

Reason for the Request: *

PLEASE REVIEW BEFORE SUBMITTING:

I understand that Therapeutic Connections will provide this information within 14 business days from receipt of the Medical Records Request and a Release of Information and that a fee for preparing and furnishing this information may be charged accordingly. The charge for medical records is .50 cents for each page of the medical record and the cost of postage and handling; a preparation fee of $22.88 if the records are being sent to another provider.

Please send all Medical Record Request to the office by fax at (443) 288-4676 or email info@therapeuticconnectionsllc.com

Submit