Transferring Out

Use this form to authorize the release of your records from Women’s Health of Greenwich to a new physician or practice.

I hereby authorize Women’s Health of Greenwich to release my medical records in its possession concerning my care to the physician or practice named below.

Records to Release

Please select what should be released *

Complete medical records including vaccinations Vaccination records only Specific treatment or date Most recent office note, labs and testing

Treatment date (if requesting a specific treatment)

Your Information

Full Name *

Date of Birth *

Email *

Phone

Address *

New Physician or Practice

Physician or Practice Name *

Address

Phone

Fax

Signature

Sign below using your mouse, trackpad, or finger.

Type your full name *

Today’s date *

Prefer to complete this on paper? Call us at (203) 822-6749 and we’ll be glad to help.

Transferring Out

Your Health.Our Priority.

Your Health.
Our Priority.