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*
Fax
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*
- CD
- Flash Drive
- Fax
- U.S. Mail
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
What area did you come from?*
Other (please specify)*
Additional Comments
Parent/Guardian Name*
First Last
This field serves as your electronic signature & authorizes the chart transfer
Parent/Guardian Phone*
Parent/Guardian Email*
Please note that Center City Pediatrics utilizes a third party, DataFile Technologies, 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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Phone
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About

Center City Pediatrics offers patients and their families access to pediatric care through friendly phone and email access and convenient office hours. Center City Pediatrics is a recognized Patient-Centered Medical Home by the NCQA.

Bala Cynwyd

33 Rock Hill Rd
Suite 170
Bala Cynwyd, PA 19004
Call: (610) 257-9000
Fax: (215) 735-5690

Center City

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

I hereby authorize Center City Pediatrics, LLC to release MEDICAL records to:

This field serves as your electronic signature & authorizes the chart transfer

Please note that Center City Pediatrics utilizes a third party, DataFile Technologies, 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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