Please fill out the information below relating to your medical record request for yourself or for your minor children. You may also make a request for patients your are the legal guardian for.

A signed copy of the records release form will need to accompany your request.  If you don’t have a signed copy to attach, click on the “Records Request Form” to download one.

Information regarding request.

  • Drop files here or
    Max. file size: 512 MB.
    • If you are making a request for medical records for a minor child or someone you are the responsible party for, you will need to put your name as the contact.
    • If you can not be reached during normal clinic hours, a valid email address should be listed to use to communicate with you.
    • Contact Phone Number. You should list a phone number where we can reach you during normal business hours.
    • Please provide us with details on what part of the patient's medical records you are requesting copies of or information about.
    • This field is for validation purposes and should be left unchanged.