Request for the Release of Medical Records
Request Type
*
I am requesting release/review of my records
I authorize the release of my records to a third party
Patient Information
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please enter the patients date of birth.
SSN (Last 4)
*
Please enter the last four digits of the patients SSN.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number (if applicable)
Please enter a valid fax number.
Format: (000) 000-0000.
Email Address
example@example.com
Where are we sending the records?
Name:
*
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Information to be released
Please select all that apply
*
Patient Care Reports
Billing Records
Start Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Delivery Method
Select all that apply
Email
Fax
Pick-Up at Area Ambulance Service
Postage (additional fee may apply)
Signature
Date of Signature
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient
Please provide the relationship to the patient if it is other than self.
Document Upload
Browse Files
Drag and drop files here
Choose a file
Please upload any relevant documentation as applicable. Ex: Death Certificates, Photo ID, Etc.
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