Request Records

Start a Release of Information request.

Tell us who you are, whose records you need and roughly what period. We reply within one business day with a secure channel for the signed authorization and a fee estimate before any work begins.

Request received

Thank you — a records specialist will be in touch within one business day with a secure upload link and a fee estimate. Your reference will be included in that email.

Do not enter clinical details, diagnoses or a full Social Security number in this form. This is an initial intake only. We will send you a secure, encrypted channel for the signed authorization and any sensitive information.

1. About you

Your full name

Organization Leave blank if you are an individual

Phone

I am requesting as

2. Whose records

Patient's full name

Patient's date of birth

Provider, hospital or clinic holding the records List each one if there is more than a single provider

3. What you need

Record types Select all that apply

Complete medical chart

Visit / progress notes

Imaging and radiology reports

Laboratory results

Billing and itemized statements

Other — described below

Date range from

Date range to

Purpose of the request

Turnaround needed

Anything else we should know Deadlines, case numbers, delivery preferences. No clinical detail, please.

4. Confirmations

I understand a signed authorization or lawful process is required before any records are released, and that Infomedic will send a secure channel for it.

I confirm the information above is accurate and that I am entitled to request these records.

Demo notice: this form does not currently transmit data anywhere. Connect it to a HIPAA-eligible form handler with a signed BAA before collecting real requests — a standard consumer form service is not appropriate for PHI.