Office Name: (From where you want records transferred from)

REQUEST FOR TRANSFER OF HEALTH INFORMATION

As required by the Health Information Portability and Accountability Act of 1996 (HIPAA) and California law, EdFiles may not use or disclose your individually identifiable health information except as provided in our Notice of Privacy Practices witho ut your authorization. Your completion of this form means that you are giving permission for the transfer of health information described below. Please review and complete this form carefully. It may be invalid if not fully completed.

I hereby request the transfer of health information for:

(Print patient¡¯s name and address)

RECORDS TO BE TRANSFERRED:

I would like the following transferred:

All the records The portion of the records concerning: (Specify type of disease, accident, dates of treatment, or other portion of records.)

PLEASE TRANSFER THESE RECORDS TO:

(Name and address of health care provider to whom the records are to be delivered.)

Administrative & Retrieval charges may apply.