Medical Records Request

Patient's Name

First NameLast Name

DOB

Date

Contact Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name

First NameLast Name

Relationship to Patient

(i.e. mother)

Email

example@example.com

Message

Medical Records Requested

Beginning Treatment Date

Ending Treatment Date

I request the records be provided to me via:

I would like the records delivered to me by:

Other

Person picking up my records (if applicable)

Please specify who

By signing this form, I understand the information in the record may include personal, sensitive information. I also understand and accept full responsibility for the medical records I am about to receive and I relinquish CTPO of any and all accountabilities concerning these medical records. I acknowledge the potential risks associated with sending medical records via email, including the possibility of unauthorized access, and consent to receive medical records electronically (if requested) from CTPO at the email address provided.

Signature

Today's Date

*If you are picking up records, please make sure to bring a valid ID.

Please call our office at (512) 478-8116 to complete payment and process your request.

Medical Records Request

Payment