Request Records
Request Your Child's Records From IPHC

Written authorization must be provided to our office to release patient records. Please fill out the form below to be assisted by a staff member in transferring records.
Email *
Patient name(s) *
Patient date of birth(s) *
Person completing form *
Phone number *
Reason for requesting records *
*If "other" please explain
Comments
I understand that patients 18 years and older must request their own records
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