Request Patient Records

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Submit a records request for an active or prior patient. Requests are processed in accordance with HIPAA and applicable state regulations. This form is intended only for attorneys and healthcare providers coordinating care.

Requesting Attorney or Provider Name

Law Firm or Practice Name

Contact Email

Contact Phone

Patient Full Name

Patient Date of Birth * required

Authorization Status *

HIPAA Authorization already on file

HIPAA Authorization uploaded with this request

Upload HIPAA Authorization (PDF)

Select File

Please upload a signed HIPAA-compliant authorization.

Record(s) Requested (select all that apply) * Required

Initial Evaluation

Progress Notes

Re-evaluations

Imaging Reports

Billing Statement

Complete Patient File

Preferred Delivery Method

I confirm that I am authorized to request these records and that the requested information is permitted under applicable privacy regulations.

Your request has been received. Please allow standard processing time unless otherwise noted.

Safe,

Gentle,

& Effective.

Fax: 678-649-2135

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