Request Medical Records

Patient First Name(Required)

Patient Last Name(Required)

Patient Address

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Requestor Type(Required)

Requestor First Name(Required)

Requestor Last Name(Required)

Requestor Address

Street Address Address Line 2 City State ZIP Code

Requestor Email Address

Phone Number

Fax Number

Reason for Disclosure

Delivery Method(Required)

Note: Any requests sent via US Postal may be delayed by 2-3 weeks.

Requested Document

Lab Reports

Billing Reports

Radiology and Diagnostic Reports

Films or Images

Visit Notes

Correspondence & Outside Notes

Miscellaneous Admin