Medical Records Request Form

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Mon - Fri 8:15-4:00PMSat & Sun - CLOSEDPrimary Care - text (904) 513-3240Pain Management - text (904) 206-71322624 Atlantic BlvdJacksonville, FL 32207

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Medical Records Requests

Patient Name(Required)

Patient Phone #

Provider (who is releasing the information): Emed Multispecialty Group
Provider Address: 2624 Atlantic Blvd. Jacksonville, FL 32207
Primary Care #: (904) 513-3240 | Pain Management #: (904) 206-7132
Provider Fax #: (904) 398-7871

Recipients Name (who is receiving the information)(Required)

Recipient Address(Required)

Recipient Phone #(Required)

Recipient Fax #(Required)

This request and authorization applies to:(Required)

ALL RECORDS

LAST TWO (2) OFFICE NOTES

IMAGING (CT SCAN, MRI, X-RAY REPORTS)

LAB AND PATHOLOGY RESULTS

BLOOD WORK, PAP RESULTS, IMMUNIZATIONS

EKG, ECHO, STRESS, MAMMOGRAPHY TEST RESULTS

OFFICES NOTES PERTAINING TO OPIOID/ALCOHOL DEPENDANCY

URINE DRUG SCREEN RESULTS

STD TEST RESULTS

HIV/AIDS TEST RESULTS (POSITIVE OR NEGATIVE)

MENTAL HEALTH TREATMENT

OTHER:

Other:(Required)

The purpose of releasing this information is (Ex: Continuity of care, transfer of care):(Required)

Signature

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Date

MM slash DD slash YYYY

This request is an exchange of health information between healthcare providers for treatment, payment, or healthcare operations, therefore a HIPPA compliant release is not required (HIPPA 164.506)

Emed Multispecialty Group
2624 Atlantic Blvd. Jacksonville, FL 32207
Primary Care: (904) 513-3240 | Pain Management: (904) 206-7132 | Fax: (904) 398-7871
www.emedmultispecialtygroup.com

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We have decades of combined experience in primary care! Whether you have a cold or just need a checkup, we’re here for you!

Convenient communication, text:
Primary Care: (904) 513-3240
Pain Management: (904) 206-7132

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By clicking “Send Request” you agree to our Terms and to receive texts for appointment purposes from or on behalf of Emed Multispecialty Group at the phone number provided above. Consent is not a condition of your request. Message and data rates may apply.

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If you need medical paperwork completed by a doctor, Emed is here for you. Below you can see our fee schedule based on what kind of documentation you need.

Administrative Paperwork Fees

Disabled Parking Permit …. Starts at $20.00
Physician Letter / Letter of Medical Necessity / Transportation .… Starts at $30.00
FMLA …. Starts at $70.00
Social Security / Disability Forms …. Starts at $100.00
Legal Documentation …. Requires a Quote
X-Ray CD …. Starts at $25.00
Medical Records …. $1.00 per page for the first 25 pages and $0.25 per page after that

Please allow 4 business days for the paperwork to be completed once payment is received

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