Request For Medical Form or Medical Records
Our office receives at least 2-3 medical records and form completion request daily. As a method to streamline these processes, please answer the questions below so that we can promptly reach out to you and assist you with your request.  In some cases a consult with the office manager will be necessary for the completion of forms and documentation. Additionally all medical leave request must first be approved by Dr. Fermo for consideration so please do not suspend work activity without prior consent and agreement from Dr. Fermo. 
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Email *
Patient Last Name *
Patient First Name: *
Phone Number *
I am requesting medical records for the following reasons... *
Required
I am requiring the following forms or letters to be completed on my behalf... *
Required
What is the official due date for the requested medical records or medical forms? *
What agency or organization is requesting your medical records or medical forms? *
Does your request require immediate action within the next 3 business days? *
Do you have any additional information that you believe will be helpful or necessary for us to consider as we process your request? *
I attest that the following information is accurate and that I am the legal requesting agent for the requested documentation. I understand that my request will be handled in the order in which it was received and expedited services may be available and will require an additional convenience fee.  *
A copy of your responses will be emailed to the address you provided.
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