medical records request FORM Your Healthcare in Your Hands Medical Records Request Full Legal Name:*Date of Birth*Phone Number:*Please provide area code and extension, if applicable Information Requested:*(e.g. Lab Results for the last 6 months; CT scans from Month/Year; Surgical Notes from appendectomy on (date), etc.) Delivery Method:* In-Person Pick Up (photo ID required at pick up) Forward Request (CMC will forward your record to another entity) Your privacy is our top priority. Once we receive this request, we will reach out to verify the owner of the information is making the request.Name of Institution Receiving Records (if forwarding request):Phone Number of Receiving Entity (if forwarding request): Before sending any medical records, we will use this information to verify the request. In order to expedite your request, please be sure to list any contact names or necessary extensions that may be helpful. Fax Number of Receiving Entity (if forwarding request):Mailing Address of Receiving Entity (if forwarding request):Information Needed By:Please allow up to a 6-week processing period for all medical record requests.
