Records Transfer

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Mercer Internal Medicine, LLC

Guy Nee, MD, FACP     Michael H. Yamane, MD, MPH, FACP

2480 Pennington Road     Suite 104     Pennington, New Jersey    08534

    Tel: (609) 818-1000     Fax: (609) 818-9800   

www.MercerInternalMedicine.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Use this form to request that medical records from another physician or healthcare facility be sent to our practice so that we may have the clinical information needed to provide you with the most thorough and high quality medical care.

Print out this form to complete. Mail or fax the completed form to your previous physician or medical facility.

MEDICAL RECORDS RELEASE

Mercer Internal Medicine, LLC

Guy Nee, MD     Michael H. Yamane, MD
Mercer Professional Center at Pennington
2480 Pennington Road
Pennington, New Jersey 08534

Tel (609) 818-1000
Fax (609) 818-9800

To (Doctor/Hospital):________________________________________________

I hereby authorize the release of my medical records to Mercer Internal Medicine, LLC.

Please send the following to the indicated address or fax number above:

                    ___All available records

                    ___Recent EKGs/Labwork

___Hospital history/physical reports and discharge summaries

___Other:____________________

Patientís name:_____________________________________________________

Patientís date of birth:__________ Patientís social security #:_______________

Patientís signature:________________________________ Date:_____________