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New Medical Records Request

Patient Medical Record Information

Patient First Name:

Patient Last Name:

Patient Date of Birth:

Requested Information

All medical records will be provided.

Include visits from today or yesterday? (May delay processing by 2 days)

To release your complete record, simply leave this item blank. To withhold certain types of information from the third party, check the box next to each type of information you wish to withhold.

Information pertaining to drug and alcohol abuse, diagnosis, or treatment

Information pertaining to mental health diagnosis or treatment

HIV/AIDS test results

Genetic testing information

Your Contact Information

We will use the mailing address on file with Comprehensive Pain Specialists.

Relationship to Patient:

Name:

Cell Phone Number:

Retype Cell Phone Number:

Email Address:

Designated Third Party Recipient

Type of Third Party Recipient:

Type of Recipient

Third Party Contact Information

Name:

Attention:

Address:

Line 2:

City:

State:

Zip:

Phone Number:

Ext.:

Fax Number:

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