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Health Records Release Form
When to Use This Form:
This form is used in either of the following situations:
1) Transferring EXTERNAL records TO a Citrus Medical Physician i.e. your old family doctor, a specialist you saw, etc.
2) Transferring Citrus Medical Records TO an external physician, clinic, or third party
How to Fill Out This Form:
1) Fill out the name and contact information of the doctor, clinic or hospital you want to request records from
2) Select from one of the following two options
3) Please sign the bottom of the form along with your name, date of birth, and date of signature.
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4) Upload the completed copy through our Contact Form. Photos of this signed document, a signed PDF copy, or a hard copy are all accepted.
Note: Transferring medical records after switching family doctors is not an OHIP covered fee. If you are requesting to transfer records TO our clinic from a previous family doctor, they should be contacting you within 1-2 weeks after we send the request. If you do not hear from them, please contact them to settle any fees required for the transfer. If you are requesting to transfer records FROM our clinic, you will be contacted with the exact fee once we have processed the request.