Electronic Record Delivery Request
This form must accompany the HIPAA Authorization to receive your medical records as electronic PDF files rather than as printed copies.
- 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.
- 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.
- 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.
- Signature and Date Line: Sign and date the form, Your signature will be verified.