Dr. John Chaffey - Medical Record Request Form
» Dr. John Chaffey - Medical Record Request Form
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Dr. John Chaffey - Medical Record Request Form
Fields
Directions - Agreement to Release Records
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Yes - I agree to have my Medical Records Released
Thank you for visiting the Medical Record Request Page for the Office of Dr. John Chaffey. We ask that you fill out ALL required fields in the form below. Please note that an e-mail address is not required, but highly recommend in order to provide basic status updates on your medical record request process. Lastly, a credit card is required and will be charged once all of your records have been completed for the printing / time / and shipping costs to get the medical records to you. Please note a signature is required in order to receive your medical records from FedEx. Please note any credit card charges will come from Epcom World Industries, Inc. the medical record fulfillment organization for Dr. John Chaffey. Medical Record Pricing Information: In accordance with Rhode Island State Law, there will be a nominal fee $0.75 per page for the first 50 pages and after 50 pages, the fee is $0.50 per page not to exceed $125 to make copies of your medical chart and mail it via certified / signature required shipping carrier. Please Note: If you are unable to agree to the medical record release process then we will be unable to fulfill your request for medical records.
Patient First Name
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Patient Last Name
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Patient Date of Birth
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Patient Address - Street Line 1
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Patient Address - Street Line 2
Patient Address - City
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Patient Address - State
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Patient Address - Zip Code
E-Mail Address
Telephone Number
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Name on Credit Card
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Credit Card Number
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Credit Card Expiration Date
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Credit Card Security Code
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Credit Card Billing Zip Code
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