Medical Records Request

Access your medical records securely and conveniently with our HIPAA-compliant service

Patient Name *

Name at Time of Treatment (if different from above)

Date of Birth *

Phone Number *

Email Address

Address *

Select the types of records you need: *

Service Date Range (Optional)

From

Additional Specification

How would you like to receive your records? *

Electronic DeliveryFastest

Secure encrypted email delivery

U.S. Mail

Physical copies mailed to your address

In-Person Pickup

Collect from our Health Information Management office

Paper Copy

Printed copies for pickup or mail

Delivery Specification

Send Records To

Complete this section if records should be sent to someone other than the patient.

Recipient Name

Recipient Address

Phone

Fax

By completing this form, I authorize Methodist Hospital for Surgery to release my protected health information as specified above.

I understand I have the right to revoke this authorization at any time by contacting the Health Information Management department
This authorization expires 90 days from the date signed unless otherwise specified
I understand that once disclosed, information may no longer be protected by federal privacy rules
Treatment will not be conditioned on whether I sign this authorization
I may inspect or copy the information to be used or disclosed

Representative Name *

Relationship to Patient *

Digital Signature *

By typing your name above, you are providing your electronic signature and consent to this request.

Date *

Time *