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*

Referring or Primary Care Doctor's OfficeConsulting or Other Doctor's OfficeHospital or Healthcare FacilitiesOther
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.
Fax Number
Please enter a valid phone number.
Types of records being requested?*

Endoscopy/Colonoscopy/Procedure ReportsPathology ReportsImaging ReportsLab ResultsConsultation/Office NotesAll Records
List of Patients*
How do you want to receive the records?*

FaxEmail (encrypted)
Medical Records Release

NOTE: If request is NOT the referring provider, a signed medical records release form is required from each patient.
Cancelof
Signature*

Clear
Please verify that you are human*
Should be Empty: