Medical Records Request Form for Clients and Guardians
Name of Client
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Who is making the request?
*
Client completing request
Guardian Completing Request
Name of Guardian
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Records Requested (check all that apply):
All Records
Treatment Plan
Progress Notes
Intakes/Assessments
Measures
Specific Dates:
If specific dates: (DOS)
Date
to
Date
(DOS).
Route in which to send records:
*
In person pick up in Grundy Center
Mail
Email
Fax
Address (If requested by mail)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (if requested)
example@example.com
Fax number (if requested)
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Request
I recognize and understand that there is a $35 document fee required in advance of receiving these documents.
I understand
I will call Heart and Solutions at (800) 531-4236 to make this payment.
Yes
Please verify that you are human
*
Submit
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