Language
English (US)
Medical Records Request Form
Please complete the following form in its entirety when requesting medical records for a patient who has or is receiving care from MIND 24-7.
REQUESTOR INFORMATION
Name of Requestor:
*
First Name
Last Name
Requestor’s relationship to the patient:
*
For example: Parent, Guardian, Provider, Case Manager, etc.
Requestor’s email address:
*
Please enter an email address in case we need to contact you. example@example.com
Requestor’s phone number:
*
Please enter your best contact phone number.
Preferred Method of Contact (Please let us know the best way to reach you if we have questions about your request.)
Email
Phone
PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Patient Date of Birth:
*
-
Month
-
Day
Year
Please enter in the following form: MM DD YYYY
STARTING Date of Service being requested:
*
-
Month
-
Day
Year
Please enter in the following form: MM DD YYYY
ENDING Date of Service being requested:
*
-
Month
-
Day
Year
Please enter in the following form: MM DD YYYY
Type of records needed:
*
For example: discharge summary, psych eval, medical eval,etc.
How do you want to receive the information?
Please Select
Email
Fax
Mail
Pickup at Clinic
FILE UPLOADS
RELEASE OF INFORMATION
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Choose a file
Do you have a signed RELEASE OF INFORMATION on file? If not, please complete one and submit it along with this request.
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of
PROOF OF IDENTIFICATION
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Choose a file
Please also include PROOF OF IDENTIFICATION such as a picture of your driver’s license, proof of agency employment, a copy of a Power of Attorney, or other forms of Guardianship papers.
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of
Submit
Should be Empty: