Patients must complete this form to request medical records to be added to their FollowMyHealth portal.
Don’t have a FollowMyHealth login? Click here to register!




    Date of Birth

    Documents to Include:
    Office Visit Notes
    Operative Report
    EMG Report
    Physical Therapy Report
    CT Report
    MRI Report
    Radiology Images on CD ($10 fee - OCI Imaging will email when available to be picked up)

    Other: free text


    Please select any information that you wish to be excluded Exclude HIV / AIDSExclude Sexually Transmitted DiseaseExclude Mental Health TreatmentExclude Drug / Alcohol Related

    By submitting this request you acknowledge that payment is required prior to release of records. An invoice will be sent to the email or fax number provided above. Delivery times are from the date payment is received.

    Your Signature

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