Submit Medical Record Request

Healthcare providers may request medical records using our form below.

Please provide either a formal letter on official letterhead with the patient’s name, date of birth, whether the entire record or specific portion(s) are needed, delivery details, and contact information, or upload a completed, signed HIPAA-compliant release form. Ensure all information is clearly printed before submission

Healthcare Organization or Provider's Name (Required)

Patient's First Name (Required)

Patient’s Last Name (Required)

Date of Birth (Required)

Patient’s Phone (Required)

Patient’s Email

Attach Cover Letter or HIPAA Release Form(Required)

Accepted file types: pdf, Max. file size: 4 MB.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Submit Medical Record Request

AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA