Medical Records Request Form

/Medical Records Request Form
Medical Records Request Form 2018-09-17T05:45:04+00:00

Authorization to copy any of your medical records must be done in writing.

Our office staff will provide your requested medical records within 30 business days unless otherwise specified.

If an insurance company is requesting your medical records, your written consent must be included, and they may be subject to a copying fee. Medical records provided to outside medical providers or patients themselves are not subject to a fee.

Step 1 of 4

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  • Name of the person or organization you would like to release you records to.
  • Name of the person or organization you would like to request your records from.