Medical Records Request

Medical Records Request

Please complete the form below to submit a medical record request.
Who is requesting medical records*
Is this a request for multiple patient medical records?

YesNo
How many patient records are you requesting?
Click here to download the patient record request template: Multiple Patient Medical Records Request Template
Please upload an excel or csv file with all requested information. Please use the link above as a template.

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Patient Name*
Date of Birth*

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Patient Phone Number
Patient Email
example@example.com
Requester name
Requester email
example@example.com
Requester phone number
Requester Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Provider
Medical Provider Location (City, State)
What information are you requesting?

Provider notes and recordsDiagnostic results (i.e. x-rays, other tests)Information used to establish a diagnosis and/or direct treatment
Please upload release of information documents below

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Release of Information (Please sign below to allow the release of your medical information)

Clear
Should be Empty: