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Medical Records Request Form

    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

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