Create Medical Records Request "*" indicates required fields Step 1 of 3 33% This field is hidden when viewing the formUser Logged In? Contact InformationYour Name* First Last Email* Already have an account?Login now.Patient InformationPatient's Name* First Last Patient's Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY SSNThis field is hidden when viewing the formWill the patient utilize an authorized representative to facilitate this medical records request? Yes No This field is hidden when viewing the formAuthorized Representative's Name First Last Facility Holding Patent's Medical Record(s)Facility Name*Full name of hospital, medical office, clinic or company holding patient’s medical records.Facility Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient IDPlease indicate the Patient identification or designation while being treated at the Facility.Is the patient still undergoing treatment in the facility?*Please indicate if the Patient is still receiving treatment from the facility. Yes No On what date did the patient start having treatment at the facility?* MM slash DD slash YYYY On what date did the patient cease having treatment at the facility?* MM slash DD slash YYYY Is the request for all records, or specific records?* All Records Specific Records What specific records are being requested?*Describe specific requested records, which may include treatment history, doctor’s notes, tests records, consultation recordsAuthorized Recipient of Medical RecordsAuthorized Recipient Name*Authorized recipient or institution which can receive the requested medical records.Authorized Recipient Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is the purpose of the release of records to the recipient?*When will the authorization of records disclosure to the recipient end?* On a specific date Occurrence of a certain event On what date would the authorization of disclosure to the recipient end?* MM slash DD slash YYYY What event would terminate the authorization of records release to the recipient?*Will the patient give consent for requested records pertainint to drug or sexual related abuse, alcoholism, mental health records, abortion?*These types of information require specific further consent to be disclosed. Yes No Will the patient give consent for requested records pertainint to HIV testing and/or AIDS diagnosis or treatment?*These types of information require specific further consent to be disclosed. Yes No What is the date of this request?*Please indicate when the Medical Records Request would be executed. MM slash DD slash YYYY PDF Preview Full Screen Rotate your phone sideways for larger preview. Almost there! Complete secure checkout on the next page to receive your PDF without any watermarks or restrictions. Click “Previous” if you still have some edits to make. Over 13K+ Reviews And 100K+ happy customers 100% Private & Secure Your important data protected
