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Medical Records Release Request

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Medical records
Patient details
Request Provider
Final Details
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Reason of requesting the Medical Record

Do you wish to state why you are requesting the medical records?

Yes No

Why are the records being requested?

Insurance-related reasons To obtain a second opinion Because of a change in providers Because of a relocation For personal reasons Other reasons

Other Reasons:

How may the Provider contact you for any questions about your request?

By phone

By e-mail

By fax

What is your fax number?

Fax

What is your e-mail address?

E-mail:

What is your phone number?

Home phone:

Work phone:

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Medical Record Authorization

Who is authorized to receive the medical records?

Name:

Address: e.g.(Street, City, State and Zipcode)

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