Step 1. Contact Information This form is confidential and HIPAA compliant First Name Last Name Phone Number Email Relationship to the patient Self Parent Spouse Guardian Other Patient Name Patient DOB Next Patient's Provider(s) Select types of Medical Record request Select Treatment Summary Full Record Billing Record Describe your Medical Record request Is the request for Medical Record for the patient themself or is there a signed Authorization to Release form already submitted in the patient's file? Yes No/Not Sure N/A. I am the patient requesting a copy of my own records. Patients need to be established with their provider minimum 3 months for any paperwork that requires disability related recommendations. Allow at least 10 business days and up to 30 days for the completion of any documents. Fees will be charged by your provider for the production of records, letters; depending on the type of request, your provider may set a flat fee or a fee in increments of 15 minutes at a rate of $250.00 per hour for therapist and $500.00 per hour for psychiatrist or nurse practitioner. Fees must be paid prior to the release of records. Any errors or missing documentation necessary to complete a medical records request may result in a delay of the release. By completing this form you are acknowledging all information provided is accurate Previous Submit Request
