Medical Record Request Form
Please fill out the Medical Record Request Form completely. You must specify:
• Who the records are being released to (eg. Dr. Smith, yourself)
• The reason for the record request (eg. transferring to a new doctor)
• What records you want released (eg. "All records" or "Everything")
• A fax number (if records are being sent to a doctor’s office)
There is no charge to transfer your medical records from Dr. Gary Seto to another physician. If you request that your medical records be released to yourself, I will charge 25 cents per page for medical records printed to paper. There is no charge for digital copies of your medical records sent via e-mail, secure messaging, or fax.
• Who the records are being released to (eg. Dr. Smith, yourself)
• The reason for the record request (eg. transferring to a new doctor)
• What records you want released (eg. "All records" or "Everything")
• A fax number (if records are being sent to a doctor’s office)
There is no charge to transfer your medical records from Dr. Gary Seto to another physician. If you request that your medical records be released to yourself, I will charge 25 cents per page for medical records printed to paper. There is no charge for digital copies of your medical records sent via e-mail, secure messaging, or fax.
| Medcal Record Request Form.pdf |
| E-mail Consent Form |
