Medical Record Request Submission

Please Do NOT use this form if you are a patient, medical provider or workers' compensation insurance carrier. Instead, please contact the Nova center that provided the medical care to obtain copies of medical records.

If you are an attorney's office, government agency, or a third party requester, please use this form to submit your request. Complete the form to submit requests for Nova medical, Radiology images and billing records. Click "Send me a copy of my responses" to receive a confirmation email. Nova Provider Deposition request can also be submitted here. Records are usually processed within 15 business days; if you have not received your records within that time please contact our records Dept.at recordrequests@n-o-v-a.com. We will make every effort to provide the records prior to the deadline. Please attach ALL requests for a patient in a single submission.

Insurance adjusters or TPAs needing records related to billing matters should contact the Central Billing Office at billingsupport@n-o-v-a.com.

Patient Name*

Last Name, First Name

Entity/Requester Name*

Entity Requesting Records

Relationship to Patient*

Select

Records Requested*

MR=Medical Records, B=Billing, Rad=Radiology Select best option from drop down menu.

Select

Authorization Type

Subpoena or Signed Release

Select

Center

If known

Select

State*

Select or enter value

File Upload*

WRITTEN REQUEST For Records +Authorization Attach ALL requests for this patient.

Drag and drop files here or

Requesters Return Email*

Please provide the Email You Would Like Records Sent. Please Note, NOVA Medical Centers does not fax records.

Email Confirmed*

By checking this box, I confirm the above email address is where the Medical Records will be sent. Please note: NOVA Medical DOES NOT FAX Medical Records.

Invoice Email*

Nova Medical Centers will send invoices to this email.

By clicking this box, you acknowledge this submission to be your official request for records.

I Accept*

Send me a copy of my responses

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