Request for medical records

Request medical records

Under the Health Insurance Portability and Accountability Act (HIPAA), you or your designated patient advocate have the right to obtain copies of your medical records. Please note: collection of medical records takes 30 days to complete. To help us serve you in a timely manner, please complete the following information.

"*" indicates required fields

* indicates required fields

Patient Name*

First Last

Patient Date of Birth*

Person Requesting Medical Records*

Patient

Parent/Guardian

Authorized Caregiver

Name (if not patient)

First Last

Email Address*