Request Your Medical Records

Please complete the following information in its entirety. Contact us with any questions at 267-339-3500 or 800-321-9999.

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

 
Release to*
Please select the release party

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

To request that we send your information to another party, you must complete this section in its entirety, and send a Release of Information Form. You can download the form by clicking on this link and follow the instructions. You will see the download link again once you submit this online form.

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
Please check the box in order to submit the request

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)

Purpose or reason for request*
Purpose For Request Required

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.)

This authorization will expire on*
Please enter an expiration date

Security Validation
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