Below are two options on how to fill out the form, please read each option.
Forms can be printed and hand carried.
Forms can be filled out and submitted via e-mail IF Adobe Reader used on the computer or mobile device. If PDF opens in a new window, download the form and open it in Adobe Reader. After the form is downloaded to your device, open it with Adobe Reader. In the form you will see fillable areas highlighted in a light blue. Click within this area to add information.
PDF documents on this page require Adobe Reader to view and to fill. You may obtain Adobe Reader for free from the Adobe website by clicking the icon. If you already have Adobe Reader installed on your computer, you do not need to install it again.
Obtaining CRCCS Medical Records
To obtain your child’s medical records, please select your primary clinic location below to download our request form.
Completed requests can be mailed, faxed, or hand carried to our office. Please allow 7-10 business days once we receive your request.
Releasing Medical Records to CRCCS
Prior to your child’s initial visit please request all pertinent medical records from your referring provider. This request must be in writing. Download and submit our form to your referring provider after scheduling your appointment.
Patients over 18 – CRCCS Disclosure Authorization
All patients over 18 years of age must submit written authorization to release both medical records and verbal communication to specified guardians. This allows our clinic to continue regular care with our 18+ patients and their families.
Please hand carry the completed form to your next visit with us.