COASTSIDE FAMILY MEDICAL CLINIC INC.
REQUEST FOR PATIENT MEDICAL RECORDS
E. Lynn Schoenmann, Trustee
Bankruptcy Estate of Coastside Family Medical Clinic, Inc.
I am a former patient (or parent/guardian of a former minor patient) of the Coastside
Family Medical Clinic Inc. I have received and read your letter of August 17, 2009 advising of
certain procedures to follow in order to obtain my medical records. I understand that if I follow
those procedures, and if my medical records are among those which were turned over to the
bankruptcy estate on May 1, 2009, and currently in storage, I can obtain those records by
completing, signing and returning this form to your office no later than August 28, 2009 either
by mail to Coastside Bankruptcy Estate, 800 Powell Street, San Francisco CA 94108; or by fax
to 415-362-0416; or by email to firstname.lastname@example.org.
I must then personally appear at the Coastside offices at 225 S. Cabrillo Highway, Suite
100A, in Half Moon Bay on either September 8 or September 9, 2009 between the hours of 1:00
p.m. and 8:00 p.m. I will be required to present a photo ID, such as my California Drivers
License, as identification, and I will be required to sign a receipt. If I follow these procedures, I
will be given my ORIGINAL medical record files. I understand that no copies of those records
will be retained. I further understand that unclaimed medical records will be destroyed on or
after August 17, 2010.
Patient Name:____________________________________________Date of Birth:___________
Parent/Guardian Name (if minor patient):____________________________________________
Signature:___________________________________________ Date Signed:____________
PLEASE COMPLETE A SEPARATE REQUEST FORM FOR EACH FAMILY MEMBER