Pyramid Healthcare

Health Record Request

This should not be an employee of Pyramid Healthcare or it's associated companies. If this is a current/previous client, this will be your name.

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Include all staff members who should part of the communication with legal counsel. This should include the executive director. clinical director/supervisor, RQM, and any staff member including in the subpoena.

Do you believe the client wants the identified party to testify and/or their records released to the requesting entity

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Please include any previously used last names if known.

If known

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If this request is being completed by a employee of PHC or its entities, please include name of staff completing the form. Do not use NA. Must include a name for communication purposes.

If request is for a client/previous client and does not include specific documents, please include what records are requested (ex, whole chart, individual notes, lab results etc)

Please upload any releases of information or supporting documentation.

*****For Previous Clients, please upload current picture identification. We will not release information without this********

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I understand a fee may be involved in the processing of the medical record, in accordance with both federal HIPAA and state laws. If applicable, payment will be required prior to the release of the record.


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