Medical Records Request Form

Patient Information

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

Requestor Information

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

Release Information
Please specify that date on which this authorization to release records expires
Please select all that apply.
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.
Identity Verification

A copy of the patient's drivers 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.

Signature of person requesting records