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.
Patient date of birth(s)
Person completing form
Reason for requesting records
Change in insurance
*If "other" please explain
I understand that patients 18 years and older must request their own records
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This form was created inside of PatientPop.