Medical Records Request Form

Patient Information
Requestor Information
Release Information

Note that any requests sent via US Postal may be delayed by 2 - 3 weeks. There is no fee for electronic delivery, and records are made available in the secure Providerflow portal as soon as they are processed.

Include?Document CategoryStart DateEnd Date
Admission / Discharge
All Clinical Written Documentation
History & Physical
Lab Reports
Immunization
Billing Reports
Radiology & Diagnostic Reports
Films/Images
Other (Specify in Comments)
Radiology Reports
Visit Notes
Procedure Reports
Correspondence & Outside Notes
Miscellaneous Admin
Patient Forms
Psychological Evaluations
Pharmacy
Other Clinical Documents
Insurance Information
If start date is not selected records will be provided for the last 24 months


Please select any information that you wish to be excluded *






By submitting this request you acknowledge that payment is required prior to release of records. An invoice will be sent to the email or fax number provided above. Delivery times are from the date payment is received.