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Medical Records Request Form
Thank you for submitting your request. To help us process and locate your medical records accurately, please complete the secure form below.
PATIENT INFORMATION
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
COMMUNICATION PREFERENCES
How would you prefer to be contacted regarding the status of this request?
*
Phone Call
Email
REQUESTOR AUTHORIZATION
Are you requesting these medical records for yourself or are you an authorizes representative?
*
I am requesting my own medical records. (A signed HIPAA release form may be required to process this request).
I am requesting records on behalf of a client or patient. (Note: Documented legal authorization or a signed HIPAA release form may be required to process this request).
SCOPE OF RECORDS REQUESTED
To help us find the specific information you need, please define the timeframe or dates of service for the records:
*
All available records
Specific timeframe
If specific time frame, please share the Start Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If specific time frame, please share the End Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: