Record Request Form
To request a copy of your mental health record, please complete the form below.
Today's Date
-
Month
-
Day
Year
Date
Client's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
I hereby request a copy of my mental health record from
Date
to
Date
.
I am requesting:
*
My full mental health record held by this office, including treatment notes
A specific portion of my mental health record, described below (ex: treatment plan, intake evaluation, discharge summary, etc.):
Please describe the portion of your record you are requesting
Please send my medical record using the following method:
*
Secure Fax
Encrypted email
Mail
Fax number where record should be sent:
-
Area Code
Phone Number
Email where record should be sent:
example@example.com
Address where record should be sent:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who is completing this request
*
Self
Parent / Guardian
Legal Representative
Name of Requestor
First Name
Last Name
Please allow up to 30 business days after you have submitted this form to complete your request. Please sign below
*
Clear
Submit
Should be Empty: