• Medical Records of Ligation Surgery

    We require the surgical notes and pathology report of your original ligation surgery.

  • MEDICAL RECORDS RELEASE

    • This form is for patients who would like NCCRM to request their medical records from their ligation surgery provider on their behalf.
    • Please note that you will need to pay a $10 non-refundable administration fee, which is not covered by insurance now or in the future.
    • Once you have made the payment, you will be directed to the Medical Records Release Authorization Form, which is legally required in order for us to request your records.
    • Please allow up to one week for your provider to release the documents.

     Step 1: Online Payment Link

    Step 2: You will be directed to the release authorization form after submitting payment.

    DO NOT SKIP STEP 2 - This authorization form is a legal requirement in order to request your records.

  • MEDICAL RECORDS UPLOAD

    • This form is for patients who already have their medical records of their ligation surgery and would like to upload them securely for NCCRM to access.
    • You may upload a PDF document or a file that contains documents.
    • You may also provide an accessible link to your documents.

     👉  Medical Records Upload Form

  • MEDICAL RECORDS WAIVER

    • This option is intended for patients who are unable to obtain their records, such as when documents have been destroyed or are otherwise unavailable for retrieval.
    • This form allows us to continue with your surgery approval and scheduling even without prior medical records.
    • We strongly recommend obtaining your ligation surgery records if possible.

     👉  Medical Records Waiver Form

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