Client/Patient Request for Records

Client/Patient Request for Records

This form is to be completed by a client/patient, or a person legally authorized to act on the client/patient behalf when they are requesting access to their own medical, clinical or business records.
Date of Request

MonthDayYear
Date
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I wish to access the following types of record:*

All recordsBilling/FinancialBehavioral OnlyMedical OnlyOther
Date of Service Start

MonthDayYear
Date
Date of Service End

MonthDayYear
Date
Please give a brief explanation for this request:
When access is granted, I would like to receive my records:*

In PersonBy Certified MailEncrypted Flash DriveEncrypted Email
I wish these records to be sent to:*

MyselfThird-Party
Third-Party Name

First NameLast Name
If you have not already completed an Authorization for Use and Disclosure for the third party receiving your records, please complete one here.
Third-Party Email
example@example.com
Third-Party Phone or Fax
Please enter a valid phone number.Format: (000) 000-0000.
Third-Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload a copy of your government-issued ID here:

Our staff will not be able to release your records until a government-issued ID is provided.
Cancelof
I understand that in very limited circumstances I may be denied the ability to inspect or obtain my records, in whole or in part, because of a potential risk to me or to someone else, or for legally permissible reasons. Medical Records will inform me in writing of any decisions including fees that were made in regards to this records request, the reason for the denial and the process of review I am entitled to. I understand the Medical Records Departments is alloted thirty (30) days to fufill the medical records request.
Name of Requestor

First NameLast Name
Signature

Clear
Relationship to Client
Should be Empty: