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• Patient Records Request Form

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• Date*
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• Patient Name Last, First, Middle, Suffix*
• Patient ID Number*
• Birthdate*
• Social Security Number*
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• Address

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Email
• Phone

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• Type of Request*

  Facility to Facility Facility to Patient (fee)
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• Request Records FROM (facility name)*
• Department*
• Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Email*
• Phone*

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• Fax*

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• Send Records TO (facility name)*
• Department*
• Address*

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Email*
• Phone*

  --
• Fax*

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• Patient will receive records.*

  Email Mail Pick Up
• Address/Email Address to Send Records (if different than above)*
• Initial here to confirm this choice.*
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• Purpose for Request* Select Continuing Care Legal Reasons Personal Reasons Other
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• Type of Records Requested* Select Entire Record Procedures/Surgeries Labs Vaccinations Specific Date Billing Records Physician Notes
• Start Date*
• End Date*
• Comments/Notes*
• Patient Records Fee
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• Signature