Medical Record Request Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
.
Month
.
Day
Year
Date
Phone Number
*
###-###-####
Email
example@example.com
Medical Records From
Facility / Entity Name
*
i.e. Eye care provider
Phone Number
###-###-####
Fax Number
###-###-####
Email
example@example.com
Medical Records To
Facility / Entity Name
*
i.e. Eye care prodvider / Self
Phone Number
###-###-####
Fax Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Request Details
Purpose of Request
*
Personal Use
Transfer of Care
Legal Purposes
504 Plan
Individualized Education Plan
Correspondence with others involved in care
Evaluation Results/Summaries
Other
Additional Notes
Delivery Method
*
Mail
Email
In-Person Pickup *Approximately $0.25 per printed page
Fax
Authorization
I, the undersigned, authorize the release of my medical records to the specified individual or entity. I understand that this information may include sensitive and confidential details related to my health.
Signature
*
Date
.
Month
.
Day
Year
Date
Relationship to Patient
*
Self
Spouse
Guardian
Other
File Upload (Optional)
Browse Files
Drag and drop files here
Choose a file
Please upload your ID, insurance card, referral, or other requested documents.
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of
Submit
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