Global Neurosciences Institute  |  PO Box 717, Pennington, NJ 08534  |  Phone: 844-464-6387  |  Fax: 215-239-3037  |  medicalrecords@gnineuro.org

If you are the patient or are requesting access as the patient's legally authorized personal representative, please use our Patient Request for Access to Medical Records form instead.

Please submit a separate request for each patient.

Important: Submitting this form does not itself authorize disclosure. GNI will review the request and supporting documentation to determine what records may be provided. The requester's signature on this form does not replace a patient authorization or other legal authority when required.

We can provide records maintained by or for GNI. If you request records we do not maintain, we will let you know and, when known, identify where you may request them.

Please request only the records relevant to your purpose. The records provided will be limited to the scope permitted by the applicable authorization or other legal authority.

Note: This form is for existing records and related records certifications. Requests for new medical opinions, disability paperwork, or other clinical forms requiring completion should be directed to the treating provider's office.

Please identify and upload the documents supporting your request. You may submit an existing signed patient authorization; it does not need to be on a GNI-branded form if it otherwise meets applicable requirements.

GNI may contact you if additional information or documentation is needed. Please contact us for an alternative secure submission method if you cannot upload your documents.

GNI will review the requested date and any applicable deadline. A requested completion date does not, by itself, confirm that GNI has agreed to that date.

GNI charges a flat $20 fee for each third-party records request, collected securely below when you submit this request. There is no per-page charge.

If you believe your request is exempt from the fee (for example, certain subpoenas, court orders, or government agency requests), pay the fee and note the exemption below. GNI will review the request and refund the fee if an exemption applies.

GNI will review and process your request promptly in accordance with applicable law and any legally binding deadline.

We may contact you for clarification, additional supporting documents, or an applicable fee estimate. We will notify you if we cannot fulfill the request as submitted.

By signing below, I certify that I am submitting this request on behalf of the organization identified above and that the information provided is accurate to the best of my knowledge.

I understand that GNI will review the request and supporting documentation before disclosing records and may contact me for clarification or additional information.

I understand that this acknowledgment does not replace any patient authorization or other legal authority required for disclosure.

Questions or assistance: Please contact medicalrecords@gnineuro.org or call 844-464-6387. Please do not send Social Security numbers, patient records, or completed authorizations through ordinary email. Contact us for a secure submission method.