Pyramid Healthcare

Health Record Request

 
 
mm/dd/yyyy
 

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.

 
 
 
 
mm/dd/yyyy
 
 

Please include any previously used last names if known.

 
 
mm/dd/yyyy
 

If known

 
 
 

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********

Drop your files here
 

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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