Medical Records Request

Please provide your information below. The details you submit will be used solely for the purpose of fulfilling your medical records request and for contacting you regarding that request. Your information will remain confidential and will not be used for any other purpose.

First name

Last name

Phone

Company name (If Applicable)

I acknowledge that the information provided in this form is accurate to the best of my knowledge and understand that it will be used solely for the purpose of processing and fulfilling a medical records request. I understand that this information is protected under the Health Insurance Portability and Accountability Act (HIPAA).

I understand that additional documentation may be required to verify the legitimacy of this request, including proof of identity or legal authorization to receive the patient’s medical records.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Patient's Information

Please provide the patient's information below. This information is required to locate and process the requested medical records accurately.

Patient's Full Name

Patient's Social Security Number (If Applicable)

Patient's Date of Birth

Month

Day

Year

Date of Service

Month

Day

Year

If you experience any issues submitting this form, please contact us by calling us at (409) 728-2464 for assistance.