Medical Records Request

Medical Records Request

PATIENTS REQUESTING COPIES OF THEIR RECORDS MUST DO SO BY CONTACTING THEIR LOCAL MYEYEDR OFFICE.

Please complete this form to request medical records for MyEyeDr patients, fill out all required fields, and upload all pertinent documentation for your request. i.e., Authorization Release, Cover Page, Transmittal guidance, etc.

Please allow up to 30 business days* for your request to be processed and completed. We will send all requested records found to the requestor via fax.

*For requests containing 25 or more patients, please compile your patient list into an Excel Spreadsheet and upload it to the appropriate section of the form. These requests will have a longer timeframe for completion.

Is this an Initial Request or Status Update Request?*

Please select what type of request you're submitting, either an Initial Records Request or a Status Update Request for a previously submitted records request.

For requests of 100+ or more patient records, the earliest Completion Date is July 1, 2025.

Patients requesting copies of their own records must do so by contacting their local MyEyeDr office.

Initial Request

Status Update Request

Please select a reason for the Status Update Request.*

Select the reason that best fits your Status Update Request.

Select

Requestor/ Recipient Information

Requestor Name*

The name of the company submitting the records request.

Requestor Fax Number*

The fax number to where you want the records transmitted.

Phone

Point of Contact Name*

The person who can be contacted with any questions regarding this records request.

Point of Contact Email*

Request Due Date*

The date by which you are requesting the records to be received.

Due Date must be at least 30 business days out from the current date.

For requests for 100+ patients, the Due Date must be set to on/after July 1, 2025.

Legal or Subpoena Request?

Please check if your records request is from a law firm or part of a subpoena request.

Patient Information/ Request Details

If you are requesting more than 1 patient's records, you may skip the fields in this section and simply upload your Excel Spreadsheet containing the patient list and all request documentation.

Patient Name

Name of the patient for which you are requesting records

Patient's DOB

The date of birth of the patient you are requesting records.

DOS Start

Date of Service start date of your request.

DOS End

Date of Service end date for your request.

Upload Documents

Please upload all documentation pertaining to your request, and if you are requesting multiple patient records, please upload one Excel Spreadsheet containing each patient's Name, DOB, and DOS Range.

Attach Documents*

Drag and drop files here or

Terms and Agreement

By checking the box below, I assert that all the information provided in the Medical Records Request Form is accurate and truthful. I fully accept responsibility for the accuracy of the information in my request and any documentation provided to MyEyeDr. I understand that my request may not be fulfilled by the requested due date, as Medical Record Requests are fulfilled on a first-come, first-served basis. I acknowledge and consent to MyEyeDr's right to charge a research and production fee for any Medical Records Request where allowed in accordance with all Federal, State, and Local laws. Furthermore, I comprehend that any misuse, misrepresentation, or unauthorized use of the obtained medical records or information may result in legal consequences for which I am solely responsible.

I have read and accept these terms as described above.*

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