Electronic Record Delivery Request Instructions
This form must accompany the HIPAA Authorization to receive your medical
records as an electronic PDF file rather than as printed copies.
Requester Name and Address: Please complete this portion completely and legibly. Failure to do so
will result in your records request not being completed.
Please provide a valid e-mail address: A confirmation e-mail will be sent to the address you provide. You must
validate the e-mail address by following the link provided. If you do
not validate the address, your records will not be sent.
Medical Records Requested: Please provide the patient’s full name, date of birth and dates
of service requested. Please be as specific as possible on the dates of service.
Signature and Date Line: Sign and date the form. Your signature will be verified.