Welcome! has partnered with to make it easy for you to request copies of medical records.
Let's get started! Which type of requester are you?
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Patient
You are the patient requesting your own records or an individual with the legal right to make healthcare decisions on behalf of the patient (e.g. parent, legal guardian, healthcare proxy, etc.). Upon completion, records will be delivered directly to you via a link sent to your email address or texted to your phone.
Third Party
You are a third party (attorney, insurance company, etc.) requesting records for someone else. You will need to supply additional documentation to verify that you're authorized to make this request.
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Important
Only copies of medical records may be requested through this site. Please contact the practice directly or use their patient portal for school, disability, or other form completion requests.
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I Understand
Location of Records
To which facility would you like to submit your request?
Page x of x
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Acknowledgement
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I Understand
Please Clarify
Are you the patient? Or, are you a representative with the legal right to make healthcare decisions for the patient?
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Your Information
Patient Information
Please enter your name, date of birth, and last four of social security number. You may include middle initial in the first name field.
Please enter the patient's name, date of birth, and last four of social security number. You may include middle initial in the first name field.
Please enter the patient's name and date of birth. You may include middle initial in the first name field.
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Your Information
Please enter your current address.
Please enter your full name and current address.
Please enter your full name, company name, and company type.
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Important Factors
Please choose any factors applicable to your request. Select all that apply or skip, if none.
Subpoena
Records are being requested under subpoena, discovery request, or other court order.
Disability / Govt Benefits
Records are being requested in relation to a claim for SSA disability benefits or other government benefit program.
Workers' Compensation
Records are being requested in relation to a claim for workers' compensation.
Investigation / Assessment
Records are being requested in relation to an investigation by government agency (e.g. DSS, DCF, CPS).
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Optional - Identifier \
Your company's identifier to help locate this request when we respond. Please do not use patient's date of birth or social security number.
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Type of Information
What type of information would you like to request from the patient's chart? What type of information would you like to request from your chart?
Note: You will have the option to restrict by date range on the next screen.
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Dates of Service
Would you like to limit the information included to a specified date range?
 
to
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Communication Preferences
Please enter at least one contact method you would like us to use when communicating with you about this request.
A confirmation message will be sent to your primary method when you press Next.
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Contact Method Verification
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Documentation / Authorization
Identity Verification
Please upload any supporting documentation including your request letter and a signed authorization.
Please upload your driver's license or other government ID. You may use the camera on your device to take a photo of it.
Please upload a driver's license or other government ID for both you and the patient You may use the camera on your device to take photos of the IDs. You should also upload any documentation you have authorizing you to request the patient's records.
  • Upload one file at a time (3 max)
  • PDF, JPG, and PNG file types accepted
  • 25 MB file size limit
  • Do not upload password protected files
Upload File
Use Camera
Close File Uploader
Having trouble? Try the
Close Camera
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Additional Information
Do you have any additional information that will help us more accurately and completely respond to this request?
Because you did not upload any supporting documentation, there is a risk that your request will be rejected. Please add any information that might helpful to us in verifying your identity (e.g. driver's license number). There are no refunds for rejected requests.
Because you did not upload any supporting documentation, there is a high risk that your request will be rejected. Please explain the lack of documentation and reason for the validity of this request.
Note
Delivery notifications will be sent via to: . Alternative delivery instructions entered below will not be honored.
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Delivery Options
Once your request is fulfilled and ready for delivery, we can send you easy-to-follow instructions for securely downloading your records. This gives you the most control over your information. You will have a copy for printing or forwarding to anyone you choose. You also have the right to request your records be sent directly to a third party.
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Ready to Submit!
Your information request is ready to send. After you click the submit button below, your request will be queued for fulfillment.
Please keep in mind that requests are processed on a first come, first serve basis and may take a few days to complete.
Your information request is ready to send. After you click the submit button below, we will create the request in our system and generate an invoice.
You must pay the invoice on the next screen before your request will be processed.
Your information request for   is ready to send. Just click submit below and you're done.
Thank you for using the   Request Portal!
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Submit
Release Authorization
Decline
Accept
Declining will cancel this request. The form will therefore not be completed which could affect your benefits.
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INVOICE
Facility RQ-ID
Patient Name Date of Birth
Description Per Qty Fee
Amount Due
TOTAL
PAYMENT
BALANCE
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Amount Due
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Submit
Download Acknowledgement
Create New Request
Our Request Portal is currently out of commission. Please try again later.
RecordQuest's Request Portal makes requesting records easy! However, we are unable to find a provider at the address you specified. It should be in the form:
Please contact your healthcare provider to get the proper link with their identifier included.
Thank you!
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[=Description]
You haven't uploaded any files yet. Use the buttons above to select files or take a photo of your identification card.
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No Fees