Dowloadable  Documents Authorization to Release Fax Cover Sheet (Record Request) These documents require Adobe Reader for complete accessibilty and functionality. Click here to download for free if you do not have this software.

Medical Records Request

In order to properly request a medical record, please complete the following form in its entirety. Download the fillable Fax Cover Sheet which must be sent with any and all of the pertinent documentation including a signed Authorization to Release statement by the patient, and any additional legal documents required such as certification letters, and subpoena(s) if applicable. Because we receive a high volume of faxes, this coversheet is designed especially to assist us in identifying and servicing your request(s) in a timely manner. All requests must be submitted on an individual basis. Please be aware that requests without this fax coversheet, and the patient's signed release statement will not be honored.

Company Contact Information
Company Name:	Required
Address:	Required
City:	Required
State:	Required
Zip Code:	Required
Phone:	() - Required
Fax:	() - Required
Requestor's Information (if applicable)
Check this box if not applicable
Who should we specifically send this medical record to?
First Name:
Middle Name:
Last Name:
Email:
Patient's Contact Information
First Name:	Required
Middle Name:
Last Name:	Required
SS#:	Required
Birth Date:	Month 1 2 3 4 5 6 7 8 9 10 11 12	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Address:	Required
City:	Required
State:	Required
Zip:	Required
Phone:	( ) - Required
Date(s) of Service:	From: Required
	Month 1 2 3 4 5 6 7 8 9 10 11 12	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
	To: Required
	Month 1 2 3 4 5 6 7 8 9 10 11 12	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
File/ Case#:

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