Existing Patient

Chief complaint Primary insurance

Insurance name

Primary policy ID Do you have secondary insurance?

Yes No

Secondary insurance

Insurance name

Secondary policy ID

Preferred day Preferred time frame Upload documents PDF or image files accepted (up to 10 files, max 10MB each)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

Chief complaint Primary insurance

Insurance company name

Primary policy ID Do you have secondary insurance?

Yes No

Secondary insurance

Insurance company name

Secondary policy ID

Upload insurance card PDF or image files accepted (up to 10 files, max 10MB each) — e.g. front and back of an insurance card

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

What's this about? What's your question? Upload a document (optional) PDF or image files accepted (up to 10 files, max 10MB each)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

Type of question Describe your question What action would you like us to take? Upload EOB or documents PDF, images, or Word documents accepted (up to 10 files, max 10MB each)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

I declare that the information I have provided is accurate and complete.

Reason for this request

Continuing care with another health care provider Other (personal copy, legal, disability, etc.)

A processing fee may apply to requests that aren't for continuing care with another provider. Our office will follow up with the amount before releasing records. Send records to

Healthcare Provider Other Contact

Healthcare Provider Details

Provider / facility name Fax number Location / address Phone number

Other Contact Details

Contact name Phone number Fax number Email Mailing address

Upload signed release form (PDF) Signed PDF only (up to 10 files, max 10MB each) — this document authorizes the release of your medical records Anything else you'd like us to know? (optional)

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request and that the uploaded release form has been signed by the patient or authorized representative.

Reason for this records request Upload your authority to request these records Signed patient authorization, subpoena, court order, or similar (up to 10 files, max 10MB each)

Patient Information

Whose records are you requesting?

Patient first name

Patient last name

Patient date of birth

Anything else you'd like us to know? (optional)

I confirm that I am legally authorized to request these medical records and that the uploaded document supports this request.

Document type

Insurance Card (Front & Back) New Patient Paperwork Existing Patient Paperwork Lab Results Other

Description of document(s) Upload scanned document(s) PDF or image files accepted (up to 10 files, max 10MB each) — select both sides if uploading an insurance card Anything else you'd like our office to know?

I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request.

Patient Forms

Who is requesting these records?

Healthcare Provider Details

Other Contact Details

Patient Information

Prefer Paper?

Existing Patient Paperwork