Secure Records Request Form

Edify Counseling Group: Records Request

Complete this form and include a valid signed HIPAA authorization (or subpoena/court order) before we can release any records.
Requester Information
Requester type
Organization or company name
Your name

First NameLast Name
Title or role
Your email address
example@example.com
Your phone number
Please enter a valid phone number.Format: (000) 000-0000.
Fax number
Client Identification
Client's full name

First NameLast Name
Client's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other names used by the client
Clinician or provider seen, if known
Records Requested
Which records are you requesting?

Other
If Other, please describe
Requested date range, if applicable
Purpose of the request
Is this request accompanied by a subpoena or court order?
Date records are needed by

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Delivery Information
Preferred delivery method
Recipient name or organization
Recipient email address
example@example.com
Recipient fax number
Recipient mailing address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Supporting Documents
Upload signed authorization or subpoena/court order

Cancelof
Photo ID (required only if you are the client or the client's parent, guardian, or personal representative)

Cancelof
Certification
I certify that I am authorized to request these records, that the information provided is accurate, and that the attached authorization is valid and unrevoked. I understand that psychotherapy notes require a separate authorization, that reasonable copy fees may apply to third-party requests as permitted by Florida law, and that Edify Counseling Group may contact the client to verify this request.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Edify Counseling Group: Records Request

Requester Information

Client Identification

Records Requested

Delivery Information

Supporting Documents

Certification