Medical Record Request Form

Medical Record Request Form

If you are a Medical Office Or Government Representive 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
Your Phone Number
Please enter a valid phone number.
Your 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:
Additional Notes
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