ADD/ADHD Records Transfer Request
Transfer to our offices: – Download
This form is to release your past medical records TO our Office . Please print this form and fill out all areas completely. It is REQUIRED that your current/previous doctor’s office has your SIGNATURE at the bottom of this form in order to process this request. Upon completion, please send this form to your current/previous doctors office and they will send your records to our office. Thank You!
Transfer to another doctor: – Download
This form is to release your medical records TO another DOCTOR, (or to yourself) . Please print this form and fill out all areas completely. It is REQUIRED that our office have your SIGNATURE at the bottom of this form in order to process this request. Upon completion, please send this form to our office via fax at (972) 212-4270 . Your request will be handled within 15 business days.
The following administrative fees apply for this service. The 2010 medical records copying fees are effective Jan. 1, 2010. In addition to the amounts listed, charges will apply for the actual cost of postage, shipping, and delivery of records.
Service
Retrieval Fee
Pages 1-20
Pages 21-60+
Charge to Patient
$0
$25.00
$.50/page
If you have any questions, please fee free to call our office at (972) 943-0410 .
ADD/ADHD Diagnostic & Treatment Center, PA
PO Box 261283
Plano, TX 75026