Please complete the following information in its entirety.
In order to protect your privacy, online requests for records will only be shipped directly to a patient's home address, a physician's office, or a state disability agency.
Requests that fall outside of the above mentioned categories require a hard-copy signature and are unable to be submitted online.
For these requests, print the Release of Information form, complete all highlighted fields and fax to 267-339-3766 for processing. Please allow 7-10 business days for completion of your request. For any questions or concerns, please call our Medical Records Department at 267-339-3784.