Request edit access
Request for Medical Records
DO NOT CLICK "REQUEST ACCESS" IN THE TOP RIGHT CORNER. Completing this form is the Request for Access.

Authorization for disclosure of Protected Health Information (PHI). The information completed below will be stored securely and a notification will be sent to the Medical Records department. Medical Records will contact you if there are any questions and will notify you when your records are ready. Due to the large volume of requests, this process can take up to 30 days.

NOTE: If you have already completed a paper form with the Medical Records office, you do NOT need to complete this online form.
Your Name *
Your answer
Your Phone Number *
Your answer
Patient Name *
Your answer
Patient Birth Date *
MM
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DD
/
YYYY
Patient Address *
Your answer
Which records are you requesting? *
Information to be disclosed *
Required
Storage *
Required
I understand that *
Required
Comments: (Please share any additional information that is relevant to helping Medical Records fulfill your request.)
Your answer
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