Medical Records Request (For Providers)

Medical Records Request (For Providers)
Name of Entity Requesting Records
Name of doctor or facility that's requesting records
Type of Provider

Other
Requesting Entity's Address

Street Address

Street Address Line 2

CityState

Zip Code
Contact Person's Name

First NameLast Name
Contact Person's Title
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Types of records being requested?
List of Patients
How do you want to receive the records?
Medical Records Release

NOTE: If request is NOT the referring provider, a signed medical records release form is required from each patient.
Cancelof
Signature
Please verify that you are human
Should be Empty: