Medical Records Request Form

Medical Records Request Form
Thank you for contacting Medical Associates Plus to request a copy of your medical records. Once your request is processed, you will receive notification and instructions on receiving the requested records.

Questions regarding the status of your request can be submitted by emailing medicalrecordsrequest@medicalassociatesplus.com.

You should receive a response from a representative shortly.
Requestor Information
Are you the patient or requesting on behalf of the patient?
Patient Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Patient Date of Birth

MonthDayYear
Date
Patient Address

Street Address

Apartment/Suite Number

CityState / Province

Postal / Zip Code
Patient Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email
example@example.com
Requestor Full Name

PrefixFirst NameMiddle NameLast NameSuffix
Requestor Address

Street Address

Apartment/Suite Number

CityState / Province

Postal / Zip Code
Requestor Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Requestor Email
example@example.com

Requestor Information