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Medical Records Request
Patient Name*
Date of Birth*
Phone Number*
Last Four Digits of SSN#*
Email*
Address
Address*
City/Town*
State/Province*
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ZIP/Postal Code*
As the patient, or the patient's personal representative, I am requesting a copy of the medical record held by Howard Memorial Hospital*
Date(s) of Service Requested*
Type(s) of Records
Summary of Record
Entire Medical Record
Emergency Room Record
Radiology
Laboratory
Operative/Pathology Report
Immunization Records
Other Information
Does request include a virtual visit?
Yes
No
Please deliver to
Patient
Other
Name
Address
Address
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
I understand the record may include information relating to mental healthcare, communicable diseases, and treatment of alcohol or drug abuse.*
NOTICE: Once your PHI has been disclosed in accordance with this request, it may be re-disclosed to individuals or organizations that are not subject to the HIPAA regulations.
I request the record to be provided in the following format
Paper
USB
Secure portal
Unsecure email
Fax
Signature*
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