Medical Records Request

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Authorization to release medical records requires written authorization by the patient. If the previous physician, lab or record holder requires payment for the records to be released to us, the patient will be responsible for any charges that apply.

First Name *

Last Name *

Date of birth *

YYYY

I request copies of the following information: (If other, please specify) *

complete medical records,

blood results,

X-ray, MRI, CT, and

Other:

Required

I request copies of the following information: complete medical records, blood results, X-ray(s), MRI(s), CT, and any other medical information to be RELEASED TO Dr. Arun Villivalam at the following address: Los Gatos Doc, Inc., 15195 National Avenue, Suite 205, Los Gatos, CA 95032

Released from: (Please provide the name, contact information, and address of your former physician / hospital.) *

I understand that I have the right to request a copy of these items upon written authorization. *

I will collect these personally.

Please mail or fax these items to my doctor or advise me to the contrary.

Signature *

Email address *

Submit

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