Request Medical Records

I’m the patientOr a parent, guardian or personal representativeDoctor, hospital or provider groupFor treatment, payment or care coordinationLaw firmWith a signed authorization, subpoena or court orderRecords retrieval or copy serviceRequesting for a law firm, insurer or employerInsurance company or adjusterAuto no-fault, workers’ comp or health planGovernment agency or courtSocial Security disability, state agencies, courts

Initial fee (not charged to patients)	$32.08
Pages 1–20	$1.60 per page
Pages 21–50	$0.80 per page
Pages 51 and up	$0.32 per page

Request medical records

About you

Patient

Records needed

Confirm it’s you

Authorization

Sign

Request received