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