Patient resources

Medical record request

Complete the form below so we can locate your chart and send the documents you need—securely and in line with HIPAA.

Information you submit is used only to process your request. We may call or email to verify identity.

We work to fulfill requests promptly. Some cases require a signed authorization or additional review.

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Request form

Fields marked with * are required. Be as specific as possible about dates and types of records (e.g. visit notes, imaging reports).

Full legal name *

Date of birth *

Location usually seen (optional)

Email *

Phone *

Preferred delivery * Mailing address (required if mailing records) Records needed *

Not for emergencies. If you are experiencing a medical emergency, call 911. By submitting, you agree we may contact you about this request.