Record Request Central Cal Orthopedic Medical Associates, Inc Patient Name: ______________________________________________ Date of Birth: __________________ Social Security Number: _________________________ I hereby request and authorize release of my patient care records from Central Cal Orthopedic Medical Associates, Inc to: Name / Entity to Receive Records: ______________________________________________ Address: ______________________________________________ ______________________________________________ ______________________________________________ Patient Signature & Date: ______________________________________________ ______________ Mail this form and retrieval / copying fee in the amount of $20 to Custodian of Records PO Box 1123 Turlock CA 95381-1123 Payment of the retrieval / copying fee by money order will speed response. Clearance of funds from personal checks used to pay the fee will be confirmed prior to processing the record request.

Record Request

Central Cal Orthopedic Medical Associates, Inc

Patient Name:

______________________________________________

Date of Birth:

__________________

Social Security Number:

_________________________

I hereby request and authorize release of my patient care records from Central Cal Orthopedic Medical Associates, Inc to:

Name / Entity to Receive Records:

______________________________________________

Address:

______________________________________________
______________________________________________
______________________________________________

Patient Signature & Date:

______________________________________________ ______________

Mail this form and retrieval / copying fee in the amount of $20 to

Custodian of Records
PO Box 1123
Turlock CA 95381-1123

Payment of the retrieval / copying fee by money order will speed response. Clearance of funds from personal checks used to pay the fee will be confirmed prior to processing the record request.