Patient Request Form

Patient Request Form
1. Requestor Name:*

FirstLast
2. Patient Name:*

FirstLast
3 . Request Type*

Family and Medical Leave Act (FMLA)Medical Records RequestUpdate Credit CardProvider Phone CallWork/School Accommodation LetterWork/School Absentee letterSurgical Clearance LetterReferral LetterFrom Referral to PCP LetterOther
3A. Request Date*
3B. Call Date/Time*
3C. If you are requesting a printout or medical records, please visit our document Paper Print policy page for pricing before submitting your request.

If you are requesting your records sent over to another provider, please fill out our Authorization To Disclose Protected Health Information form
4. Telephone Number:*
5. E-Mail Address*
6. Disclosing Party:*
Name of Person or Facility
7. Person or Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
8. Phone Number:*

Area CodePhone Number
9. Fax Number:*

Area CodePhone Number
10. Email*
example@example.com
11. Reason For Request:*
12. Signature*

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