• Medical Record Request

    Mandel Dermatology
  • What is your relationship to the patient who you are requesting records for?*

  • ALERT:

    If you are the patient, requesting your own record, you must use a different request form.

    You can access the form here:
    https://www.mandeldermatology.com/records-request---patient

  • Are the records you are requesting being use to seek government benefits?*
  • Please note, there is a $0.75 per page fee for requested records, unless you are exempt from payment. You are only exempt from payment if it is required by law for your specific situation.*

  • Patient Record Information

    Please enter the information for the patient you are requesting records for. For multiple requests, this form must be submitted once for each patient.
  • Patient's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a completed HIPAA Release form signed by the patient?*

  • ALERT:

    A HIPAA Release From must be completed and signed by the patient before you are able to request any records. Please use the following link to find the HIPAA Release form. Once it is completed, you may return to this form to request your records.

    You can access the form here:
    https://irp.cdn-website.com/234c9825/files/uploaded/hipaa-release-form.pdf

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  • Request Details

    Please let us know what you are requesting. We suggest only requesting what is necessary, to minimize any costs or delays associated with pulling and sending your records.
  • Are you requesting the entire medical record for the patient?*
  • What parts of the record are you requesting?*
  • Are you requesting the above for all dates, or specific dates?*
  • Where should we send the requested records?*
  • Would you like to share any additional information with us regarding your request?*
  • Should be Empty: