Request Your Medical Records

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.

Fields marked with (*) are required

First Name*
Please enter your first name

Last Name*
Please enter your last name

Date of Birth*
Please enter your date of birth

 
Address*
Please enter your street address

City*
Please enter your city

State*
Please select a state

Zip*
Please enter your zip code

Phone*
Please enter a valid phone number

E-mail*
Please enter a valid email address

 
Person or Company Name*
Please enter a person or company name

Address
Please enter your street address

City
Please enter your city

State
Please select a state

Zip
Please enter your zip code

 
What information are you requesting be disclosed?*
Please describe what medical records are to be disclosed

Authorization

In the event that any of the foregoing information contains mental health records, genetic information, venereal disease-related records, tuberculosis-related records, drug and alcohol treatment records, and/or HIV/AIDS-related diagnosis and treatment information, I specifically authorize release of such information (By checking this box you agree)

Please check the box in order to submit the request
Purpose or reason for request*

I knowingly and voluntarily authorize the Rothman Institute and its employees and agents to use and/or disclose protected health information (PHI) about me in the manner described in this authorization. (If you are a patient, you may type “my personal request” in the box below.)

Purpose For Request Required
This authorization will expire on*
Please enter an expiration date

Security Validation
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