Medical Records Request Form
Please fill out this form to request medical records.
Requestors Name
*
First Name
Last Name
Requesting Agency
Date
*
-
Month
-
Day
Year
Date
Email
*
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Full Name (if different)
*
First Name
Last Name
Date of Birth of Patient
*
-
Month
-
Day
Year
Date
Please upload a valid photo ID if you are the patient or a signed Release of Information form authorizing this request if you are a requesting party.
*
Browse Files
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Please upload the appropriate documentation to verify authorization for this request. If you are the patient/client requesting your own records, please upload a valid government-issued photo ID (driver’s license, state ID, or passport). If you are a provider, agency, attorney, school, or other third party requesting records on behalf of a client, please upload a current Release of Information/Authorization form signed and dated by the client. The authorization must clearly permit the release of records to your organization. Requests may be delayed or denied if the required documentation is incomplete, expired, unsigned, or does not match the information provided on this form.
Cancel
of
Purpose of Request- Select All that apply
Entire Record
Clinical Treatment Documentation
Billing Records
Treatment Summary
Other
If selected other please explain
Purpose of Request?
Please Select
Personal Use
Transfer to another provider
Insurance
Legal
Other
Preferred Delivery Method
*
Simple Practice Portal
Mail
Fax
Delivery Address, or Fax Number. If Simple Practice Portal was selected please put NA.
*
Additional Comments or Instructions
Authorization Signature
*
Submit Request
Submit Request
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