Request for Release of Medical Information
Submit your request for medical records by providing the required information and uploading a fully-executed HIPAA release.
Requester Information
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization Name
*
Fax Number
*
Email Address
*
example@example.com
Name
*
First Name
Last Name
Patient Information
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Medical Record Details
Information to be Released (please specify the type of records needed)
*
Date Range (From)
*
-
Month
-
Day
Year
Date
Date Range (To)
*
-
Month
-
Day
Year
Date
Supporting Documents
You must attach a fully-executed Authorization below.
Attach HIPAA Release (required)
*
Upload a File
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of
Attach Additional Supporting Documents (optional)
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of
Include Billing Records?
*
Yes
No
Does your request require a certificate of custodian or affidavit to be completed?
*
Yes - Document Attached
No - None Required
UPLOAD RECORDS TO SEND
Browse Files
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of
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