(* If you wish you can print, fill, and take a picture of your forms with your smart phone and upload them to us.)

Permission for Use or Disclosure of Your Health Information

Downloadable Forms

HA Grand MD PA requires a completed and signed authorization for release of health information form before releasing any documents to anyone.

To Have Medical Records Sent TO HA Grand MD PA.

To have your records sent to HA Grand MD PA from another provider or facility, please print and fill out our MEDICAL RECORDS RELEASE FORM
and give it to the provider or facility who will be sending our office your records. You may also bring the pre-filled out form with you to your first office visit and we will gladly fax it over to their office for you.

To Have Your Medical Record Sent FROM HA Grand MD PA To A New Provider or Facility.

To have your records sent to another healthcare provider or facility, please print and fill out our MEDICAL RECORDS RELEASE FORM and mail or fax it to our office. Please allow a week for the records to be faxed over to your new provider.

Request a Copy of Your Medical Records.

To request a copy of your medical records, please fill out the following MEDICAL RECORDS RELEASE FORM and mail or fax it to our office.

The following fees will apply to this request:

  • Pages 1-20, $25 
  • Every additional page, $.50 each
  • Shipping cost, will vary. You may pick up your records in person to save on shipping costs.
  • There is no charge if you wish to have a copy of your record faxed directly to a physician or healthcare facility.

* Our average turnaround time for processing requests is 7 business days plus shipping time. Unless otherwise requested, records will be sent through US Mail.

In an effort to maximize your visit with our physician or practitioners, we recommend that you complete the Patient Registration forms prior to your first office visit.

3 options are provided for your convenience:

1. Simply print out the Patient Registration forms, fill in the information requested, and bring the completed forms with you to your first visit.

2. You can fill out and submit the Patient Registration forms by clicking on the link below. 

3. If you prefer to complete the New Patient Registration forms at our office, please arrive 30 minutes prior to your appointment time.