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Records Request Form

Please complete the online Records Request Form. Required fields are identified with an "*" in the field name.  If you prefer to print out a copy and bring it to the office, please use the link in these instructions.

Records Request Form

All information is encrypted

Select your primary office location:
Charlotte Hall Office
Waldorf Office

Enter ###-##-####

Use today's date for a new request. This request is valid for one (1) Year from this date.

Name, Address, Phone Number and E-Mail Address Required

I hereby authorize and request you to release the following medical records in your possession concerning my cancer diagnosis and/or treatment. Please add the date below to each type of record you are requesting. If you want all records released, select the All Records Checkbox below and add the date in all seven (7) record types below.

If faxing or using postal mail, please send it to your primary office location:

Charlotte Hall Office

30077 Business Center Drive

Charlotte Hall, MD. 20622

Phone: 301-884-2508

Fax: 301-884-2476

Waldorf Office

11340 Pembrooke Square #201

Waldorf, MD 20603

Phone: 301-705-5802

Fax: 301-843-1704

Please note: that you must submit the form to save any information.  Leaving the page will not save any of your insurance information.

Records Request Form

All information is encrypted

Select your primary office location:
Charlotte Hall Office
Waldorf Office

Enter ###-##-####

Use today's date for a new request. This request is valid for one (1) Year from this date.

Name, Address, Phone Number and E-Mail Address Required

I hereby authorize and request you to release the following medical records in your possession concerning my cancer diagnosis and/or treatment. Please add the date below to each type of record you are requesting. If you want all records released, select the All Records Checkbox below and add the date in all seven (7) record types below.

If faxing or using postal mail, please send it to your primary office location:

Charlotte Hall Office

30077 Business Center Drive

Charlotte Hall, MD. 20622

Phone: 301-884-2508

Fax: 301-884-2476

Waldorf Office

11340 Pembrooke Square #201

Waldorf, MD 20603

Phone: 301-705-5802

Fax: 301-843-1704

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