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 additional delivery fee for electronic delivery (there may be a retrieval fee), and records are made available in the secure Providerflow portal as soon as they are processed.

Include?Document CategoryStart DateEnd Date
Other (Specify in Comments)
Visit Notes
DDS Disability Documentation
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.