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 Requesting on behalf of patient
Patient Full Name *

Prefix First Name Middle Name Last Name Suffix
Patient Date of Birth *

Month Day Year
Date
Patient Address *

Street Address

Apartment/Suite Number

City State / Province

Postal / Zip Code
Patient Contact Number *
Please enter a valid phone number.
Patient Email *
example@example.com
Requestor Full Name *

Prefix First Name Middle Name Last Name Suffix
Requestor Address *

Street Address

Apartment/Suite Number

City State / Province

Postal / Zip Code
Requestor Contact Number *
Please enter a valid phone number.
Requestor Email *
example@example.com

Requestor Information