Request for Health Information

Request for Health Information

Patient Last Name*

Patient First Name*

Patient Middle Initial

Name at Time of Treatment

If different than above

Patient Date of Birth*

Patient Phone Number

Patient Email Address

Patient Street Address

City

State

Location of Treatment

Zip

Date of Service

What Records are you Requesting?*

Select

Specific Test Results

Select or enter value

Specific Other Records

Select or enter value

How would you like your records produced?*

Select

Other Electronic Record Method

Where would you like the Information Sent*

Select

Personal Representative Name

Personal Representative Mailing Address

Personal Representative Email

Acknowledgement of Requestor*

Patient or Personal Representative Name

Relationship to Patient

Signature*

Electronic Signature Acknowledging above Request

Signature Date*

File Upload

Drag and drop files here or

Send me a copy of my responses

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