Record Request Forms

Whether you’re new to our practice or need to leave our practice, you can use the forms below to facilitate the process.

Use our Records Release Form to have your records mailed over to us from your current practice.

  • Record Request Form From Previous Practice

    If you are leaving the area or if your child has reached the age of 24, we request that they seek an adult primary care physician. We feel that at that age, they would be better served by a health care provider that specializes in adult health. Please fill out the Record Request Form, and specify whether you want your records printed on paper or sent electronically through the web portal. We are happy to have provided care for your child over the past several years.

    You have the option to complete this form on-line or you can print it, fill it out, and send it to our office. To request and receive your records on-line, sign into your web portal account, click on patient forms, and complete the Record Request Form located at the top of the list. If you choose the paper option, please mail it, fax it to 781-944-0232, or stop by our office to drop it off.

  • Record Request Form On-Line. (Sign into your web portal account to access this form)
  • Record Request Form (Print and Send – Paper Option)

    Records Printed On Paper
    If you choose to have your records printed on paper include a $25 fee per child. You can call our office and we will accept payment over the phone. Once we receive this signed form and a payment, we will mail out the records to you.

    Records Sent Through Web Portal
    To have your records sent through our web portal, you must have been registered with us prior to this request. Please contact us if you have forgotten your username or password and we will be glad to reset the account for you. We charge a fee of $10 per child to send your records as a pdf attachment through the web portal. Once we receive this signed form, and a payment, we will send you your records.