TO USE THIS REQUEST FORM, FILL OUT THE REQUIRED FIELDS, INPUT YOUR PAYMENT INFORMATION, AND CLICK SUBMIT. ONCE SUBMITTED, YOU WILL SEE A CONFIRMATION PAGE, INDICATING THAT YOUR PAYMENT WAS SUCCESSFUL AND THAT OUR OFFICE HAS RECEIVED YOUR REQUEST. PLEASE NOTE, OUTBOUND RECORDS REQUESTS REQUIRE PAYMENT OF THE $20 PROCESSING FEE BEFORE ANY REQUESTS CAN BE ACCOMMODATED.
SENDER'S NAME
Date
-
Month
-
Day
Year
Date
PATIENT'S FIRST NAME:
*
PATIENT'S LAST NAME:
*
PATIENT'S DATE OF BIRTH:
*
/
Month
/
Day
Year
Date
WHO WILL THE RECORDS BE SENT TO?
ME (THE PATIENT)
DOCTOR OR HOSPITAL
ANOTHER PERSON
WHO SENDING TO (OUTPUT)
NAME OF PERSON WHO WE ARE RELEASING RECORDS TO (THE RECIPIENT)
*
RECIPIENT'S ADDRESS
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
RECIPIENT'S PHONE NUMBER
*
Please enter a valid phone number.
RECIPIENT'S FAX NUMBER
Please enter a valid fax number.
WHAT INFORMATION WOULD YOU LIKE RELEASED?
*
ALL HEALTH CARE INFORMATION
HEALTH CARE INFORMATION RELATING ONLY TO A SPECIFIC TREATMENT, CONDITION, OR DATE(S) (SPECIFY BELOW)
OTHER (SPECIFY BELOW)
PLEASE SPECIFY WHICH INFORMATION YOU AUTHORIZE RELEASE OF (RELATED TO A TREATMENT, CONDITION, OR DATES)
*
PLEASE SPECIFY WHICH INFORMATION YOU'D LIKE RELEASED (OTHER)
*
SIGNER'S FULL NAME
SIGNATURE
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RECORDS RELEASE PROCESSING PAYMENT
THERE IS A REQUIRED FEE OF $20 IN ORDER FOR OUR OFFICE TO PROCESS AND FULFILL YOUR REQUEST. ONCE SUBMITTED, YOU PAYMENT WILL BE PROCESSED, AND THE REQUEST WILL AUTOMATICALLY BE SENT TO OUR OFFICE.
WOULD YOU LIKE A RECEIPT AND CONFIRMATION EMAILED TO YOU?
*
YES
NO
WHAT IS YOUR EMAIL ADDRESS?
*
example@example.com
Payment Summary
*
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Records Release Processing
$
20.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
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