Medical Records Request
Party Requesting Records
Tell us who is requesting the records
*
Required Information.
First Name
*
Last Name
*
Firm Name
Email
*
Email address to send our request for payment
CC Email
Street Address
Street Address Line 2
City
State / Province
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Records Being Requested
Patient's First Name
*
Patient's Last Name
*
Patient's Date of Birth
*
-
Month
-
Day
Year
Patient's MRN (if available)
Patient's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please describe the records you are requesting, including each procedure along with the date performed.
*
A duly executed medical records release is required to release these documents to a third party.
*
A release is already on file with HMCA/Stand-up MRI
Attach a release below
Please attach a Patient Record Release form in order for us to expedite the release of Medical Records.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
sysAccountName
sysAppointmentID
sysOrderID
sysPatientID
sysCareflowPrefillID
userrole
sysUserName
Should be Empty: