Pyramid Healthcare
Health Record Request

Today's Date

mm/dd/yyyy

Name of Person Requesting Health Information

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.

Request Type

Requesting Company

Date of Request

mm/dd/yyyy

Client First Name

Client Last Name

Please include any previously used last names if known.

Client's Date of Birth

mm/dd/yyyy

Client's Medical Record Number

If known

Treatment Facility Location (s)

Are you an employee completing the form?

Notes

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)

File Upload

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

Payment Understanding

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.

Send me a copy of my responses

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Pyramid Healthcare Health Record Request

Pyramid Healthcare
Health Record Request