1. Enter Request Information
  2. Upload Authorization
  3. Review and Submit

New Medical Records Request


Facility / Facilities


Patient Information

Please select the visits/admissions you would like released:

Please select the type of information you would like released:
Medical Records
Itemized Billing
Radiology Images (The Radiology Department will follow up if any charges or additional information is required.)


Purpose of Request

Please enter your reason for requesting records.

Your Information


Delivery Information



Delivery Notes

Normal processing time is 5 business days from time of receipt. Please contact us if you have any questions.


Are you sure you want to delete this request? This will stop all work on fulfillment and a new request will have to be entered.

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