DELAWARE MODERN PEDIATRICS, P.A.

David M. Epstein, M.D.

300 Biddle Avenue, Suite 206

Springside Plaza, Connor Building

Newark, Delaware 19702

Phone: (302) 392-2077

Fax: (302) 392 - 0020

www.DelawareModernPediatrics.com

Medical Record Transfer Request

I, ___________________________________________, am the responsible party for the below listed minor(s)

I am requesting and authorizing ______________________________________ (name of former practice) to transfer all protected health information in your possession (the entire medical record) for the below listed minor(s) be transferred in electronic or paper format to:

DELAWARE MODERN PEDIATRICS, P. A.

300 Biddle Avenue, Suite 206

Springside Plaza, Connor Building

Newark, Delaware 19702

Minors:

Full Name Date of Birth

Full Name Date of Birth

Full Name Date of Birth

Full Name Date of Birth

I understand that this authorization is valid for 180 days. I clearly understand the content of this form.

Signature Date

Relationship to Minor(s)