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New Medical Records Request

Patient Medical Record Information

Patient First Name:

Patient Last Name:

Other Patient Names (Optional):

Patient Date of Birth:

Requested Information

NOTE: You must request any Physical Therapy (PT) records directly from your PT provider.
No imaging is provided as part of this request. Please see imaging request instructions on previous screen.

Requested Records:

ALL written records

Include visits from today or yesterday? (May delay processing by 3 business days)

Requestor Contact Information

Relationship to Patient:

Name:

Cell Phone Number:

Retype Cell Phone Number:

I cannot receive text messages at this phone number. (You will be contacted by email, which may add an additional 3 days of processing time.)

Delivery Method for Imaging CD(s)

Please select a delivery method for your imaging (X-Ray, MRI) CDs. For mailing, please allow an average of 7 additional business days.

CD Delivery Method:

Please note: The CDs you receive will contain images only. Please allow 3-5 days for your CD to be prepared. For mailing, allow an additional average of 7 business days for delivery. If you requested written medical records, they will be delivered online to you within 48 hours of receipt of your request (excluding weekends/holidays).

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