Chart Request Form

I hereby authorize Center City Pediatrics, LLC to release records regarding my child’s medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from other health care providers that the above named health care provider may hold, by means of mail, fax, or other electronic methods to:
Office Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Date of Request*
Month
Day
Year
How Many Children?*
- One (1)
- Two (2)
- Three (3)
- Four (4)
- Five (5)
- Six (6)
Child's Name (1)*
First Last
Child's DOB (1)*
Month
Day
Year
Child's Name (2)*
First Last
Child's DOB (2)*
Month
Day
Year
Child's Name (3)*
First Last
Child's DOB (3)*
Month
Day
Year
Child's Name (4)*
First Last
Child's DOB (4)*
Month
Day
Year
Child's Name (5)*
First Last
Child's DOB (5)*
Month
Day
Year
Child's Name (6)*
First Last
Child's DOB (6)*
Month
Day
Year
Method of Delivery*
- CD
- Secure Email – if selected, email address required
- Fax – if selected, fax number required
- U.S. Mail
Fax*
“Please note: there is a maximum of 100 pages deliverable via fax. Charts larger than 100 pages will default to mail records.”
Which best describes your reason for transferring? (please select all that apply)*
- Moving out of area
- Transitioning to adult practice
- Distance and convenience to my home (too hard to get to)
- Unsatisfied with the quality of care
- Unsatisfied with the access to appointments
- Other
Chart dates requested*
- Last year of records
- Last 2 years of records
- All records from initial appointment
Records released will include contents regarding drugs/alcohol/substance abuse, psychiatric/psychotherapy/mental health, tests for antibodies to HIV, HIV diagnosis/treatment, and genetic information. Your signature authorizes release of all medical records unless otherwise specified.
Please note: Records received by our office from prior physicians will not be released. Please contact your prior provider(s) for those records.
What area did you come from?*
Other (please specify)*
Additional Comments
This field serves as your electronic signature and authorizes the chart transfer, effective immediately. Authorization may be revoked at any time effective upon receipt, but will have no impact on uses or disclosures made while the authorization is valid. Your signature also indicates your understanding that you:

May not further use or disclose the medical information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law;

May be charged for copying costs;

May request a copy of the health information that is being authorized for disclosure;

Recognize that a photocopy of this release is as effective as the original;

May request a copy of this authorization.
Parent/Guardian Name*
First Last
Parent/Guardian Phone*
Parent/Guardian Email*
Relationship to Patient*
Please note that Center City Pediatrics utilizes a third party, ScanStat, to handle the transfer of charts. You can reach them directly with questions at 816-437-9134. Please allow 7-10 business days for processing.

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Bala Cynwyd

33 Rock Hill Rd
Suite 170
Bala Cynwyd, PA 19004
Call: (610) 257-9000
Fax: (484) 270-8133

Center City

1740 South Street
Suite 200
Philadelphia, PA 19146
Call: (215) 735-5600
Fax: (215) 735-5690

Fishtown

2365 East York Street
Philadelphia, Pennsylvania 19125
Call: (215) 278-2500
Fax: (215) 644-9083

Please note that Center City Pediatrics utilizes a third party, ScanStat, to handle the transfer of charts. You can reach them directly with questions at 816-437-9134. Please allow 7-10 business days for processing.

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