Medical Chart Transfer

MEDICAL CHART TRANSFER RECORDS REQUIRED

What medical information do you require with the transfer of your chart?*

Appletree will provide you with your digital Medical Records from 2007 until present. There is a $45 + HST administrative fee for this service. Please allow 4 to 6-week turnaround time. If you require records prior to 2007, additional fees may apply to retrieve your records from our archives.

Include ALL medical records, including those dating prior to 2007.
Include ONLY medical records from 2007 to today.

Where would you like the medical records to be sent?*

Your medical records will be provided via USB Flash Drive and will be mailed to you or your new physician.

Send the medical records to myself.
Send the medical records to my new healthcare provider.

PATIENT INFORMATION

Patient's Name (same as on your OHIP card)*

First Middle Last

Patient's Date of Birth*

Patient's Address*

Street Address Address Line 2 City Province Postal Code

Patient's Main Contact Phone Number*

Patient's OHIP Health Card Number + Verification Code

Please enter your OHIP health card number and verification code in the following format: 0000-000-000-AA

Are you requesting the medical release on behalf of yourself or someone else under your care?*

Patients over the age of 16 years should complete the form themselves. For dependants and attorneys of personal care, you will be asked to provide a copy of your power of attorney document.

I am requesting for myself
I am requesting on behalf of my child
I am requesting on behalf of a dependant
I am requesting as the patient's attorney of personal care

What is your name?*

First Middle Last

The parent or Legal Guardian's Name

Is your address the same as the patient?*

Yes, my address is the same.
No, my address is not the same.

What is your address?*

Street Address Address Line 2 City Province Postal Code

What is your main contact phone number?*

NEW MEDICAL PROVIDER

Please provide us with information regarding the medical provider you require the medical records to be sent to:

Physician's First & Last Name*

First Last

Name of Healthcare Facility*

Address*

Street Address Address Line 2 City Province Postal Code

Physician's Office Phone*

Physician's Office Fax*

PATIENT CONSENT

Please type your signature (Enter first and last name)*

Upload your document here:*

If you are the patient’s attorney for personal care, we require a copy of the power of attorney. If you are a divorced or separated parent of a dependent patient, we require a copy of an agreement or court order that grants you the authority to make this request. If you are the patient’s legal representative or the executor/executrix of the patient’s estate, we require documentation evidencing the same. Please note that all requests are subject to Appletree’s review prior to releasing the patient’s medical record, and we reserve the right to request further documentation and clarification prior to release.

Accepted file types: pdf, jpg, png, Max. file size: 2 MB.

Date*

Consent*

I agree to the release of my medical records and provide my consent.

I authorize the release of my medical records in accordance with the specifications listed above. I understand that once submitted, written notice is necessary to cancel this request. I understand there is an administrative fee of $45.00 + HST to recover the cost of compiling, copying, mailing and archiving the charts.

Payment

Medical Chart Transfer*

Price:

Credit Card*

Card Details

Cardholder Name

Services