Submit Medical Record Request

Healthcare providers may request medical records using our form below.

Please provide either a formal letter on official letterhead with the patient’s name, date of birth, whether the entire record or specific portions are needed, delivery details, and contact information, or upload a completed, signed HIPAA-compliant release form.

Healthcare Organization or Provider's Name

Patient's First Name

Patient’s Last Name

Date of Birth

Patient’s Phone

Patient’s Email

Attach Cover Letter or HIPAA Release Form Accepted file types: PDF. Maximum file size: 4 MB.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Submit Medical Record Request

AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA