Medical Records Request

Medical Records Request

Use this form to request access to your own records, or to submit a request as the patient’s legally authorized personal representative
Patient Information

Please provide the name used when receiving care at GNI and your current contact information. If your name has changed, please include your previous name. We may contact you to verify information before providing records.
Full Name

First NameLast Name
Previous Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Your Information
Who is submitting this request?
Representative's full name

First NameLast Name
Relationship to Patient
Legal Authority to Act for the Patient
Representative's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Representative's email
example@example.com
Supporting Documentation

Cancelof

Preferred Delivery Method

Please select the delivery method you are requesting. We will provide records in the requested form and format when readily producible. If that is not possible, we will contact you to agree on an alternative.
Preferred Delivery Method
Full Name

First NameLast Name
Email Address
example@example.com
Confirm Email Address
example@example.com
Ordinary email is not encrypted. Information sent this way could be intercepted or read by someone other than the intended recipient. A secure electronic delivery option is available.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Confirm Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Actual postage charges may apply where permitted by law. We will disclose any charge in advance.
Same as patient's mailing address above or different address
New Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Office
Please describe what you need

Patient or Personal Representative Acknowledgement & Electronic Signature
We will process your request promptly, no later than 30 calendar days after receipt unless a different timeframe is permitted or required by applicable law. We will explain any legally permitted delay or denial in writing.

GNI does not charge a copying fee for patient copies. If you request delivery by U.S. mail, actual postage charges may apply where permitted by law. We will disclose any charge in advance.
By signing below, I request access to the records identified in this form. I certify that I am the patient or the legally authorized personal representative identified above and that the information I have provided is accurate to the best of my knowledge.
Electronic Signature
Date of Signature

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Questions or assistance: Please contact medicalrecords@gnineuro.org or call 844-464-6387. Please do not send Social Security numbers or detailed medical information through ordinary email.
Should be Empty:

Information to be Released