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Request to Transfer /
Copy / Inspect Medical Records
If you are leaving
our practice and would like us to send a copy of
your child's medical records to your new
pediatrician, obtain a copy of your child's medical
records, or review your child's chart:
- Click on the link to open the PDF file (below)
- Print the form
- Fill out the the requested information
- Sign the form
- Either mail or fax the form to South East
Bay Pediatrics
Please allow 2 weeks from the time
we receive the form to process the request. If you
are requesting to review your child's chart, we will
be contacting you to make appropriate arrangements.
Please note that we will send copies of your child's
medical records to your new pediatrician free of
charge. However, there is a charge if you are
requesting a hard copy of the chart for your
records.
To complete the request form, please download and print this document:
Authorization to Transfer / Copy / Inspect Health
Information FROM South East Bay Pediatrics
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