Medical Records Request (For Patient)

Medical Records Request (For Patient)
We charge a small processing fee to process your medical record requests depending on how you want your records sent: $8 for printed copies to be picked up in our office, and $15 for printed copies to be mailed. Please note, we can only send copies of your medical records to the email address on file or the mailing address on file. The process fee is waived if your records needs to be faxed to another doctor's office, hospital, or any healthcare facility.
Patient's Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Gender*

MaleFemale
Patient's Phone*
Patient's Email*

Confirmation Email
What type of medicals records to are you requesting?*

Consultation/progress notesProcedure reportsPathology/biopsy resultsLab resultsImaging results (no CDs)

Where to send records?

Emailed to email address on file$ Free

Printed for pick up$8.00

Mailed to address on file$15.00

Faxed to another doctor's office$ Free

Faxed to a hospital or healthcare facility$ Free

Provider's Information To Fax Records
Provider's Name*

First NameMiddle NameLast NameTitle
Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Provider's Phone*
Provider's Fax*
Hospital's or Healthcare Facility's Information
Facility's Name*
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Facility's Ward, Unit, Floor, or Room Number.
Facility's Phone*
Facility's Fax*
Signature*

Clear
Must be signed of patient, healthcare proxy, or medical power of attorney.
Please verify that you are human*
Should be Empty: