Medical Records Release - Falls Church Healthcare Center

Name*

First Last

Date of Birth*

Phone*

Email

Will FCHC be SENDING or RECEIVING your medical records?*

I want FCHC to release my medical records to myself or my doctor.
I want a doctor/hospital to release my medical records to FCHC.

I hereby authorize Falls Church Healthcare Center to provide / release the medical records as specified below:*

To myself
To my physician’s office

How will you receive your medical records?*

I want them mailed to me.
I will come to Falls Church Healthcare Center to pick them up.

The cost of mailing via USPS Priority Mail ($9.65) will be added to any processing fees. Records will be sent by priority mail.

Records pick-up can be scheduled on Wednesdays 9:30 – 4:30 or Saturdays 11:00 – 12:00.

Please provide your mailing address:*

Street Address Address Line 2 City State ZIP Code

Physician / Medical Practice Name*

Physician / Medical Practice Phone Number*

Please send records to my doctor via:*

FAX
mail

The cost of mailing via USPS Priority Mail ($9.65) will be added to any processing fees.

Special Instructions

Reason(s) for Request (check all which apply)

For continuing care
For permanent transfer
Insurance submission
Other

Other – please specify

Specify medical records requested*

Complete medical records
Only for specific service dates
Only laboratory results as noted
Other

Specific Service Dates*

Specific Laboratory Results*

Other (please specify)*

Physician / Medical Practice Name*

This could also be the name of a hospital / ER / Urgent Care

Physician / Medical Practice Phone Number*

Physician / Medical Practice FAX Number

if available

Specify medical records requested*

Specific Service Dates*

Specific Laboratory Results*

Specific Exam Notes*

Other (please specify)*

Please upload an image of your photo ID*

Max. file size: 2 GB.

Signature

Today's Date

Please only press the “Submit” button once. This may take a few moments as we need to upload your photo ID.
You will receive a confirmation email when this has been successfully submitted.