Medical Records Release / Request Form
We safeguard the privacy of our patients. To have your records released or collected, complete this form and press submit.
Patient Information
First Name
Last Name
Patient's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Monday -Day -Year
Patient's Phone Number
-
Area Code
Phone Number
I understand that my request for medical records may include information relating to Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Virus (HIV), behavior health services / psychiatric care, alcohol and substance abuse, and venereal/sexually transmitted disease.
Click to confirm you read and understand.
Tell us what you need by completing this section:
I want my medical records:
OBTAINED from a provider outside of IGIC.
Released to another provider.
Printed and I will pick them up from IGIC Chelmsford office.
Other
For the purpose of :
To be seen by Integrated GI Consultants
Moving outside the area
Second opinion
Other
Indicate the specific information to be disclosed:
Office notes
Procedure reports
Recent Labs
Recent Images
Other
In need records from this date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
mm/dd/yyyy
To this date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
mm/dd/yyyy
Full name of provider to obtain /send medical records:
Person you wish to request records from or release records to
Provider's Phone
-
Area Code
Phone Number
Provider's Fax
-
Area Code
Phone Number
Provider's Email (if applicable)
example@example.com
The authorization may be revoked in writing at anytime, except to the extent thta action has been taken in reliance on this authorization. Unless otherwise revoked sooner, this authorization will expire sixty days from the date I sign it. Printed name below will be accepted as signature.
Full Name of Patient or Legal Representative
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Submit
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