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Adamstown Eye Care, LLC

2654 N Reading Rd

Reinholds, PA 17569

(717) 484-0934

Medical Record Transfer Request

Transferring a medical record is generally simple, but because it takes time and the costs can vary, it helps to understand the process. Instructions for obtaining and completing the Medical Record Transfer Request Form are located at the bottom of this page. Before you proceed, please review the following answers to the most common questions:

Who can request the transfer or receipt of a medical record?

A medical record can be legally transferred by the patient, a legal representative of the patient, or a third party designated by the patient.

Where can the medical record be transferred?

A medical record can be legally transferred to or from the patient, a legal representative of the patient, or a third party designated by the patient.

How is the transfer authorized?

The transfer is authorized in writing only. A temporary verbal authorization may be accepted when legal identity can be verified in order to facilitate service, but a written authorization will be required before the record is transferred.

What is included in the medical record?

The complete medical record includes all of the pages that describe the patient’s history and presentation as well as the doctor’s exam findings and medical plan. It also includes care communications between the doctors and other health care providers.

What is not included in the medical record? The medical record does not include billing or insurance histories and it does not include copies of records from other doctors or care facilities. Documents generated from other offices must be requested from the facilities where care was rendered. The record does not include written prescriptions that are valid to be filled. Filling a medication or prescription eyewear order through the casual interpretation of recorded exam findings is a violation of State and Federal Law.

What is the fee for the service? Our current charge is $1 for each page prepared up to a maximum of $60, plus $2 for each page prepared from digital studies or images that must be converted into print form, plus $17 to transfer the medical record by mail, fax, email, other electronic means or to any third party. The $17 transfer fee is waived if the record is picked up at our office by the patient or a legal representative of the patient. Our fees are well below the maximum set by the PA Department of Health. To provide a quote and process the payment, the exact number of pages in the medical record and the preferred method of transfer have to be confirmed. Normally, a quote can be provided within 2 business days. There are no refunds for preparation or transfer services that have been completed after the request is confirmed.

How long will the transfer take? It may take us up to 30 days from receipt of the completed request and payment of the fee to prepare and transfer the medical record. This 30-day limit is common among health professionals, although there is no specific time limit set by any agency. The record may be transferred sooner. There are no options for rush processing and preferential requests cannot be honored. All requests for medical records are satisfied in a manner meant to promote the effective continuation of care.

What if there is an urgent need for the medical record? In the case of urgent care requests, it is usually quicker to have the doctors consult with each other directly by phone. We will also respond ASAP to written requests from other professionals. Fees may still apply depending on the nature and timing of the communication.

How do I request the transfer? Contact us or phone 717-484-0934 to receive a quote for the service cost and obtain a free copy of the Medical Record Transfer Request form. You may also download it HERE. Return the completed form with your payment to us. You may mail the form, scan it and email, fax or deliver the form to us in person. You may also complete the form in person at pick-up, but payment must still be made before the record is prepared. Instructions for completing the form are included below.

Instructions for obtaining and completing the Medical Record Transfer Request Form: Contact us or phone 717-484-0934 to receive a quote for the service cost and obtain a free copy of the Medical Record Transfer Request form.You may also download it HERE. The form must be completed by the patient or a legal representative of the patient. Use only one form for each transfer request. A duplicate form is required for any alternate or repeat transfers.

Enter the date and print the name of the patient record requested. Complete one of the two outlined sections indicating whether you want to have the record transferred TO our office or TO another party. Carefully indicate the party which is to receive the record along with their exact mailing address, fax or email. You may indicate “Self” to have the record transferred to yourself. Be certain to review the Privacy Notice and Agreement of Responsibility. The patient or legal representative of the patient must sign and date the form. Complete the patient date-of-birth, address and phone number for identity verification.

Leave the bottom space blank for our use when the transfer has been completed.

Location
Find us on the map - Across from Weaver Markets at the light at RTs 272 and 897

Hours of Operation

Closed Major Holidays

Office Hours

Monday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Tuesday:

9:00 am-1:00 pm

2:00 pm-8:00 pm

Wednesday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Thursday:

9:00 am-1:00 pm

2:00 pm-8:00 pm

Friday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Saturday:

Varied Sats 9am - 1pm

Sunday:

Closed