Federal law gives you the right to a copy of your own medical records — and to send that copy wherever you choose. We make the request, follow up with your providers, and deliver your records securely. No cost to you.
When someone else requests your records on your behalf — without you — providers often treat it as an outside request and charge accordingly. When you ask, and simply tell them where to send the copy, it's still your request. That's the law, and it's the difference this form makes.
You're not sharing anything you haven't already chosen to share. You're just telling your provider where your copy should go.
Add every doctor, hospital, clinic, or imaging center involved in your care. Each one gets its own request, signed by you.
By signing below, you're confirming this is your request for your records — and telling each provider listed above where to send the copy.
By signing, I confirm that I am the patient named above (or their authorized personal representative), and that I am requesting my own protected health information be sent to the recipient I've designated, under my rights described in 45 C.F.R. § 164.524. I understand I can revoke this request in writing at any time.
Most records arrive within 1\u20133 weeks. Some providers take longer \u2014 if that happens, we'll keep following up on your behalf, including by phone, until your records are released.