• appointment scheduling
• walk in hour
• health forms
• referrals
• prescription refill
• medical record release
• change of address

Medical Record Release

At your request, we will provide you with a copy of your child(ren)'s medical records. We must have a release form signed by you. Instructions for obtaining your child's records:

Instructions

1. Your medical records can only be released when:

• this form is completed,
• signed by the parent, patient or legal guardian,
• signed by a witness, and
• returned to us by mail.

2. You may obtain this form by printing it from this web page or by calling our office at (617) 735-8585 ext. 6. We can send the form to you or fax it to you. We need your original signature when you return the form so please mail it back to us.

3. There is a processing fee of $15 associated with this request, an amount established by state law. Please enclose a check payable to Centre Pediatric Associates, P.C. or provide your credit card information with your request.

4. Every effort will be made to process your medical release request within 14 working days.

5. Click here for a printer safe copy which you can complete and mail to us at

   Centre Pediatrics Associates, PC
   Attn: Medical Records
   One Brookline Place
   Suite 327
   Brookline, MA 02445