REQUEST PATIENT RECORDS

PLEASE FILL OUT AND PRESS SUBMIT BUTTON AT BOTTOM OF THE PAGE

PATIENT NAME
**If the patient had a name change, please list the name used at the time of the exam**
**ALL INFO IS REQUIRED**
TitleFirstLastMISuffix
Address:
City: State/ZipCode
Birthday
Cell Phone of Person Requesting:
Email to send records or request further information
Is the person requesting the information same as the patient?

Parent/Guardian Information **If the patient is 18+ years old currently, consent must be noted in the patient's record that the person other than the patient requesting the information has access to the records.

Name of Person Requesting Information Other Than Patient

Birthday of Person Requesting Information

Relationship to the patient

Is The Address the Same as Patient? Please check here:

IF ADDRES IS DIFFERENT, PLEASE FILL OUT THE FOLLOWING INFORMATION:
Address

CityStateZipCode
This records request form is to send your records by E-mail or receive information on how to obtain the records by other means. The person filling out this form assumes responsibility for the information to be factual and used for non-malicious intent.


PLEASE CHECK WHAT RECORDS YOU ARE REQUESTING:

Current valid prescription only - please allow 3-5 business days
**Please note that we cannot send expired prescriptions. Glasses have a 2-year expiration and contacts have a 1-year expiration**
Copy of records from 3 years ago until present - expect 2-4wk arrival
All records - may take up to 30-60 days for retrieval
Other - please fill out request in section below


Full records may take up to 60 days to send, and records beyond 10 years may not be retrievable. Photos or images may be subject to fees. FEES FOR PAPER COPY OF RECORDS WILL BE INCURRED AND MUST BE PAID BEFORE THEY ARE PRINTED.

DO YOU CONSENT TO SENT TO SEND THE RECORD(S) THROUGH UNSECURED E-MAIL?

The information requested will be sent by a non-encrypted email. By checking yes, you have read or are familiar with the limits of privacy through non-encrypted email at www.hhs.gov. If you check "no", we can e-mail information on other means of obtaining the records, or we will by default upload the information to the portal (instructions will follow).

WOULD YOU LIKE A TEXT CONFIRMATION THAT THAT THE RECORD(S) WERE SENT?

Date of Request

ALL INFORMATION IS REQUIRED (EXCEPT IF PARENT/GUARDIANSHIP DOES NOT APPLY).
PLEASE PRESS WHEN FINISHED.