Medical Records Request

Medical Records Request
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Social Security No. *
Last four digits
Phone (In case we need to contact you about this request) *

Area Code Phone Number
Date Last Seen *
If unknown, please give approximate year.
Physician Name *
Record(s) Requested *
I am requesting that my medical records be sent to:
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Signature *

Use your mouse or finger to draw your signature above Clear
Date *

Month Day Year
Date
Time *

: Hour Minutes AM/PM Option
The information authorized by this release may include data about communicable or venereal diseases which may contain, but is not limited to diseases such as hepatitis, syphilis, gonorrhea, and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome or AIDS.

IMPORTANT NOTICE: This facsimile transmission contains confidential information, some or all of which maybe protected health information as defined by the federal Health Insurance Portability & Accountability Act(HIPAA) Privacy Rule that belong to the sender. This transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure under applicable law. If you are not the intended recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified that any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. Please notify the sender by telephone (number listed above) to arrange the return or destruction of the information and all copies
While reasonable efforts are made to respond to all contact requests in a timely manner, any urgent medical conditions or symptoms should be addressed with your healthcare provider immediately. If your condition is urgent in nature, please call our office.
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