If you are a third party and have been authorized to request medical records, you will need to submit an authorization form along with your request.
Download our fillable PDF authorization form and complete.
Print the document and sign. Note: handwritten signatures are required.
To submit the authorization, please do one of the following:
Note: the document must be filled out completely and handwritten signatures are required.
If you're submitting the form below from a mobile device, you may receive an error. Please follow the link below to avoid any errors when submitting the referral form.