Medical Records Request

REQUEST FOR MEDICAL RECORDS
Who is Requesting Medical Records *

Physician's Office Patient Lawyer's Office Disability Company
Person Requesting Medical Records *

First Name Last Name
Contact Number *

Area Code Phone Number
Requester's E-mail
What Medical Records are you needing?

Procedure Notes from Legacy Surgery Center Clinical Notes from Legacy Neuro Spine and Brain Specialists All
Please explain what medical records are needed.
Begining Date of Medical Records Being Requested

Month Day Year
Last Date of Medical Records Being Requested

Month Day Year
PATIENT INFORMATION
Patient Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Work Number

Area Code Phone Number
E-mail
Should be Empty: