Date of Birth

Requestor Information

Requestor Type

*if Attorney Requestor Type is selected, request must originate from the requesting attorney office on letterhead

Release Information

Delivery Method
Note that any requests sent via US Postal may be delayed by 2 - 3 weeks. There is no fee for Secure Electronic Delivery (InteliChart no fee)
Documents to Include:
Office Visit Notes
Operative Report
EMG Report
Physical Therapy Report
CT Report
MRI Report
Radiology Images on CD ($10 fee)

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