Psychological Records Request
Must be completed by adult patient or legal guardian. We can not release results of inpatient evaluations, as these are transcribed into the facility's medical record, and the facility is the custodian of the records.
Email address *
Name of patient *
Your answer
Patient's date of birth *
Your answer
Provide exact start time of your outpatient appointment to confirm your identity. *
Time
:
Provide exact date of your outpatient appointment to confirm your identity. *
MM
/
DD
/
YYYY
I agree that my account will be paid in full prior to receiving records. To pay your balance, please visit nollpsychgroup.com/payments (You must agree to make this request) *
I want my records sent to me by email. I understand that email is not an entirely secure means of transmitting information, but I agree that my records can be sent in this fashion. (You must agree to make this request) *
If you are requesting that your records be sent to a mental health provider or physician, please provide the provider's name and their fax number. *
Your answer
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