Patient Request for Medical Records

Date

Patient Name

First Last

Patient Name at time of Treatment

First Last

Date of Birth

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What records do you want: (Check appropriate boxes below):

If you answered Test Results or Other, please specify your answer

Beginning Date of Service

Ending Date of Service

Purpose

How would you like your records delivered?

If Electronic Delivery, Please Specify your answer

Where do you want the information sent?

Self

Personal Representative (Indicated below)

Personal Representative

Recipient Name

First Last

Relationship

Personal Representative is

HCPOA

Executor of the Estate

Legal Guardian

Other

Recipient Phone

Recipient Fax

Recipient Email

Recipient Address

Street Address City State / Province / Region ZIP / Postal Code

Date