Medical Records Request Form

To request medical records, please complete this form and download the Authorization for Release of Information form, fill it out, and sign it. When completing the Medical Records Request form, please upload the signed form.

Download the Form Here: Authorization for Release of Information

Person Requesting Records

First Name

Last Name

Phone Number

Patient Name

First Name

Last Name

Date of Birth

Upload Signed Authorization for Release Form

One file only.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.