You can request that your medical records be transferred to or from Premier Family Medicine by completing our Medical Records Release form. Please select the appropriate form below.
Please remember that privacy laws require that this form be signed by the patient requesting records, unless the patient is under 18 years of age or there is a power of attorney for an adult patient (this document will be required).
Medical Records Release to Premier Family Medicine. Print form, Complete all sections, Sign and Date, Send to the Provider(s)
Medical Records Release from Premier Family Medicine. Print form, Complete all sections, Sign and Date, Send to Premier for processing. Please be aware that there is a charge for this service. State Fees are $15 retrieval fee plus 0.65 per page up to 30 pages and 0.50 per page over 30 pages plus postage.