Medical Records Request

Who is requesting medical records: *

I am the patient or patient's parent/guardian	A legal entity
A government representative	Other

Please note that patient or patient's parent/guardian medical records requests should be handled directly by the clinic in which they visited. Please visit our FIND A CLINIC page to find the contact information for your local clinic.

Affiliation to patient: *

Requestor Name: *

Requestor Email: *

First Name of Patient: *

Last Name of Patient: *

Patient DOB: (MM/DD/YYY) * +

Patient's State: *

Type of records requested: *

Other type of records requested: *

Dates Range for Records: *

Specific Dates

All Records

Records From: (MM/DD/YYYY) * +

Records To: (MM/DD/YYYY) * +

Please upload any necessary documentation:

Please click "submit" to process your records request