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Please fax or return this form with your signature(s) in the appropriate spots to us promptly.  All requests made after November 28, 2018 will be assessed Maryland Medical Record copying fees and allowed charges irrespective of method delivered.  Per HIPAA regulations medical record copies sent via fax must be to a secure fax machine.


 Please mail this form and send payment calculated below to  

Marcia D. Wolf, M.D. 
4725 Dorsey Hall Drive, Suite A903
 Ellicott City, Maryland  21042. 
410-461-1299  



 Medical Records release

Please release my medical treatment records held by Marcia D. Wolf, M.D. to:



_________________________________________________________

_________________________________________________________

_________________________________________________________

Phone #__________________________        Secure Fax #____________________________





____________________________________              __________________________                 
PATIENT FULL NAME                                                               Date of Birth

  _____________________________________                __________________________ 

       PATIENT SIGNATURE                                                               Date

______________________________________________________________________________________

Charges as applicable and allowable by law are below for the records you requested.  




_______ # of pages @ $0.83 per page                                                                  $________________


Processing fee as allowable by law                                                                        $22.88


Postage (please allow for large envelope or priority mail charges)                  $________________



                                          Total due                                                                $_______________



PLEASE MAKE CHECKS PAYABLE TO:       Marcia D. Wolf, M.D.
                                                                        4725 Dorsey Hall Drive, Suite A903
                                                                        Ellicott City, MD  21042

TIN:  52-2219856