Medical Records Request Form

Patient Information

Please complete this section with the name and contact information that your provider would have on file.

mm/dd/yyyy
Requestor Information

The contact information for the person or organization that the records should be sent to:

(not required)
*Invoices are sent to email on file and records can be sent securely upon request.
Release Information
Examples: Patient Request (self), Disability, Insurance, Attorney, Workers Comp, Etc.
(not required)
(mm/dd/yyyy) - Please specify the date on which this authorization to release records expires
Please select all that apply.
mm/dd/yyyy
mm/dd/yyyy
Comments and Exclusions
Select any sensitive information that, if available, you do not authorize us to release. If no information is selected you authorize us to release any and all information in your file.Please select all that apply.
Identity Verification

A copy of the patient's driver's license or other valid documentation (such as patient release documentation, letter of representation, etc.) is required for processing.

Only PDF, PNG, and JPG file types are accepted.. Only PDF, PNG, and JPG file types are accepted.
Signature

Signature of person requesting records

submitting