Electronic Record Delivery Request Instructions
This form must accompany the HIPAA Authorization to receive your medical
records as electronic PDF files rather than as printed copies.
Requester Name and Address: Please fill out this portion completely and legibly. Failure to do so
will result in your records request not being completed.
Please provide a valid e-mail address: A confirmation e-mail will be sent to the address you provide. You must
validate the e-mail address by following the link provided. If you do
not validate the address, your records will not be sent.
Medical Records Requested: Please provide the patient’s full name, date of birth and dates
of service requested. Please be as specific as possible on the dates of service.
Signature and Date Line: Sign and date the form, Your signature will be verified.