Chart Request Form I hereby authorize Center City Pediatrics, LLC to release MEDICAL records to:Office Name*Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Date of Request* MM DD YYYY 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)* MM DD YYYY Child's Name (2)* First Last Child's DOB (2)* MM DD YYYY Child's Name (3)* First Last Child's DOB (3)* MM DD YYYY Child's Name (4)* First Last Child's DOB (4)* MM DD YYYY Child's Name (5)* First Last Child's DOB (5)* MM DD YYYY Child's Name (6)* First Last Child's DOB (6)* MM DD YYYY Method of Delivery*CDSecure EmailFaxU.S. MailFax*“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 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 CommentsParent/Guardian Name* First Last This field serves as your electronic signature & authorizes the chart transferParent/Guardian Phone*Parent/Guardian Email* 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.