Request for Health Information

Patient Information

Patient Last Name

Patient First Name

Patient Middle Initial

Name at Time of Treatment

If different than above

Patient Date of Birth

mm/dd/yyyy

Patient Phone Number

Patient Email Address

Patient Street Address

City

State

Zip

Please enter a Specific Date of Service OR a Date Range of Services

Date of Service

Service Date Range

Format DD/MM/YY - DD/MM/YY or MM/YY - MM/YY

Record Information

Location of Treatment

What Records are you Requesting?

How would you like your records produced?

Other Electronic Record Method

Requestor Information

Where would you like the Information Sent

Acknowledgement of Requestor

Patient or Personal Representative Name

Relationship to Patient

Signature

Electronic Signature Acknowledging above Request

Signature Date

mm/dd/yyyy

File Upload

Drop your files here

Send me a copy of my responses