Request For Medical Form or Medical Records

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Our office receives at least 2-3 medical records and form completion request daily. As a method to streamline these processes, please answer the questions below so that we can promptly reach out to you and assist you with your request. In some cases a consult with the office manager will be necessary for the completion of forms and documentation. Additionally all medical leave request must first be approved by Dr. Fermo for consideration so please do not suspend work activity without prior consent and agreement from Dr. Fermo.

Email *

Patient Last Name *

Patient First Name: *

Phone Number *

I am requesting medical records for the following reasons... *

Legal Proceedings

School/Academics

Life or Health Insurance

Short-Term Disability

FMLA - Family Medical Leave Act

Social Security Disability

Other Medical Provider or Continuum of Care

I am not requesting medical records at this time

Transfer Psychiatric Care (Establishing care with a new doctor)

Other:

Required

I am requiring the following forms or letters to be completed on my behalf... *

I do not require assistance with Medical Forms or Letters

School Medication Administration Form

Field Trip Medication Form

Homebound

Academic Accomodations

504 Plan or IEP Letter

Emotional Support Animal (ESA)

Treatment Summary Letter - Letter includes Diagnosis, Treatment and History of Medications

School or Work Excuse

Short-Term Disability

Long-Term Disability

Social Security Disability

Court Document - Examiner Report and Affidavit Regarding Capacity (Form 539GC)

Court Document - Physican Affidavit for Emergency or Temporary Proceedings Form (522GC)

Court Document - Notice of Deposition

Workers compensation Forms

Jury Duty Letter

College Leave of Absence or Letter of Return from Leave

Other:

Required

What is the official due date for the requested medical records or medical forms? *

What agency or organization is requesting your medical records or medical forms? *

Does your request require immediate action within the next 3 business days? *

Do you have any additional information that you believe will be helpful or necessary for us to consider as we process your request? *

I attest that the following information is accurate and that I am the legal requesting agent for the requested documentation. I understand that my request will be handled in the order in which it was received and expedited services may be available and will require an additional convenience fee. *

I DO agree with the following terms

I DO NOT agree with the following terms

Other:

A copy of your responses will be emailed to the address you provided.

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