Record Request Form

Information on individual requesting records

Name of Requestor (required)

Phone Number (required)

Fax Number

Email (required)

Street Address

Address Line 2

City

State

Zip Code

Information on records being requested

Date of Incident/ Date Range of Records Being Requested (required)

Address of Incident (required)

Patient Name if EMS (Authorization required. See below))

For medical records please include an "Authorization to Release Medical Records."

Please describe the records you are requesting and any additional information that will help us locate the record for you. (required)

Method of Delivery (required)

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

I agree to use electronic records and signatures

Additional File Upload if Needed

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