Medical Records Request

I am hereby requesting a copy of my record as outlined below. The medical records may include patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. I understand that my requested health record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse, unless exclusion is specified below. Please check below if you would like to exclude any of the following information.

The Date(s) of Service requested (Required)

Please select your reason for requesting medical records (Required)

Release medical records to me via (Required)

Person completing this request (Required)

Applicable Fees & Delivery Expectations

There is no fee for patients to access their records in the patient portal. Fees may apply for other release methods and vary based on the type and purpose of the request. Records shared directly with healthcare providers for continuity of care are provided at no cost, other types of requests—such as those from legal representatives, insurance companies, or for personal use—may be subject to processing and copy fees. All requests are processed in accordance with applicable federal and state regulations and are generally fulfilled within a standard timeframe following receipt of a complete and valid authorization. Requestors will be notified in advance if any fees apply.

Attestation Statement

I hereby request access to my medical record (or the record of the patient for whom I am the legal representative). I attest that the information I have provided in this request is true and accurate. I understand that knowingly providing false information may result in denial of this request or other penalties under applicable law.
I further acknowledge that my electronic signature below shall be valid and binding as my legal signature for the purposes of this request, consistent with federal and state law, including HIPAA (45 C.F.R. § 164.524).

By checking this box and typing my name below, I agree that my electronic signature has the same legal effect as a handwritten signature.

Signature of Member or Legal Representative (Required)

Date (Required)

Request to Access Protected Health Information Form

Patient Details

Medical Records Request

Applicable Fees & Delivery Expectations