Page 2 Requesting records from: Name of Practice: Name of Physician: Fax number: Address: Types of records we are requesting and all types of records you have for this patient ☐Any visit notes orders ☐Doctor ☐Doctors room notes notes ☐Emergency ☐Nurses care notes summary ☐Urgent ☐Discharge and physical reports ☐History ☐Lab progress notes reports ☐Hospital ☐Radiology or procedure notes ☐Operation ☐Consultations notes ☐Clinic ☐Other reports ☐Pathology Records within the following dates: records for this patient ☐All dated between and ☐Records Please send records to: Attention: At fax number: Or mail to: For any questions please call (phone number): and ask for:
Page 2 Requesting records from: Name of Practice: Name of Physician: Fax number: Address: Types of records we are requesting ☐Any and all types of records you have for this patient ☐Doctor visit notes ☐Doctors orders ☐Emergency room notes ☐Nurses notes ☐Urgent care notes ☐Discharge summary ☐History and physical ☐Lab reports ☐Hospital progress notes ☐Radiology reports ☐Operation or procedure notes ☐Consultations ☐Clinic notes ☐Other ☐Pathology reports Records within the following dates: ☐All records for this patient ☐Records dated between and Please send records to: Attention: At fax number: Or mail to: For any questions please call (phone number): and ask for:
healthlittoolkit2-tool11e.docx