Medical Records Release Form - Novapsy printable pdf download

Medical Records Release Form - Novapsy

DEAR PATIENT:

PLEASE COMPLETE THE FOLLOWING RELEASE OF INFORMATION AND RETURN

IT EITHER BY FAX OR MAIL TO THE ATTENTION OF MEDICAL RECORDS-

MARYANN.

Please make sure to complete the entire form and at the BOTTOM OF THE RELEASE

PLEASE MAKE SURE TO FILL OUT YOUR CONTACT PHONE NUMBER, so that

Medical Records can contact you with any questions or to collect the fee for the copying

of your records.

FEES INCURRED FOR REQUESTING COPIES OF YOUR RECORDS:

$10 processing fee

$0.50 per page for (pages1-50)

$0.25 per page for (pages 51-over)

Payment will be due when records are ready for pick up or if you need them mailed a

credit card payment will need to be received, prior to records being sent.

MEDICAL RECORDS CONTACT NUMBER: Maryann 703-698-5220 EXT 316

OUR FAX NUMBER IS 703-573-2351 – ATTN: MEDICAL RECORDS/MARYANN

EMAIL COMPLETED FORM TO MARYANN:

MAILING ADDRESS:

Novapsy – Attn: MEDICAL RECORDS

8500 Executive Park Avenue

Suite 200

Fairfax, VA 22031

Any questions, please contact Medical Records directly.

Thank you for your cooperation.

Novapsy

8500 Executive Park Avenue  Suite 200  Fairfax, Virginia 22031

703.698.5220  703.573.2351 (fax)

Medical Records Release Form - Novapsy