Please use this form if you wish to receive a copy of your medical chart, or a limited part of your medical chart. You may use this form to allow us to send records to your other care providers, to yourself, or to another designated 3rd party. Please note that for paper copies of records we charge $.25/page plus a $15 processing fee and shipping if they are mailed (no shipping charge if they are picked up). You may also elect to receive them on a USB, and will be charged $15 for the USB plus the cost of shipping (no shipping charge if they are picked up). Due to the private nature of the information contained in your medical files, all records that are mailed are done so with Recipient Signature Required. This means the person they are released to will be the person who must sign for the package. At this time there is no fee for faxing your records to you or a third party.
This form must be returned as a hard copy original to our office. You may mail it to our Mail Only address at 448 Ignacio Blvd, #294, Novato CA 94949, or dropped off at our office either in-person, through messenger service or other means.