I hereby request (name of physician, hospital or other healthcare provider) _________________________________________________________

   to give me access to medical information for (patient's name) ___________________________________________________________________

            To:  Women Physicians Ob-Gyn Medical Group

                    2485 Hospital Drive, Suite 221, Mt. View, CA 94040

Inspection. I understand that you may charge me for reasonable clerical costs incurred in making the records available for inspection.

Copies or Transfer. I understand that you may charge me a reasonable charge of up to twenty-five cents ($0.25) per page, or fifty cents ($0.50) per page for copies from microfilm, plus any additional reasonable clerical costs incurred in making the records available. I further understand that you may charge me your     actual costs for copies of any X-rays or tracings derived from electrocardiography (E.K.G.), electroencephalography (E.E.G.) or electromyography (E.M.G.).

Date:  ________________________________________

Signed:  ________________________________________________________________________________________________________________

Print Name: _____________________________________________________________________________________________________________

Telephone: ______________________________________________________________________________________________________________

If not signed by the patient, please indicate relationship: