Electronic Record Delivery Request

Click here to print the Electric Record Delivery Request form

This form must accompany the HIPAA Authorization to receive your medical records as electronic PDF files rather than as printed copies.

1. Requester Name and Address: Please fill out this portion completely and legibly. Failure to do so will result in your records request not being completed.
2. Please provide a valid e-mail address: A confirmation e-mail will be sent to the address you provide. You must validate the e-mail address by following the link provided. If you do not validate the address, your records will not be sent.
3. Medical Records Requested: Please provide the patient’s full name, date of birth and dates of service requested. Please be as specific as possible on the dates of service.
4. Signature and Date Line: Sign and date the form, Your signature will be verified.