Medical Record Request Form

Medical Record Request Form

If you are a Law firm or third party requesting patient/client information please fill this out
Patient Information
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.
Date(s) requested - Please Chose First Date Of Service (Must Match Auth. Form)

MonthDayYear
Date
Date(s) requested - Please Chose Last Date Of Service (Must Match Auth. Form)

MonthDayYear
Date
Requestor Information
Name

First NameLast Name
Firm Name
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice/Firm Phone Number
Please enter a valid phone number.
Practice/Firm Email (link to records will be sent here)
example@example.com
Delivery Method

Your Records will be sent via a secure e-mail which will give you access to a medical records portal within 48 Hours. See picture below for example:
File Upload - You Must Upload A Medical Release Form And/or Subpoena

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Additional Notes
Medical Records Request Form

This form is used to securely process your payment for a medical records request. Your information is protected and processed through Stripe, a trusted and secure payment platform. Please fill out the required fields below to complete your request.

Medical Records RequestRecords Request Fee

$35.00 Quantity

Billing Records Request Billing Records Request Fee

$35.00

X - Ray Record RequestRecord Request Fee

$100.00

Total

$0.00

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.
Date

MonthDayYear
Date
Signature

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Patient Information