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Home
Services
Individual Therapy
Couples Therapy
Teen Therapy
Family Counseling
Child Therapy
Anger Management
Online & In-Person Therapy
Insurance
Current Clients
Patient Portal
Billing & Insurance help
Medical Record Request
Provider Referrals
Resources
Therapists
Our Mission
Leadership Team
Career
Blog
FAQ
Links
Privacy Policy / HIPAA
Contact Us
Menu
Medical Record Request Form – Third Party
Home
Medical Record Request Form – Third Party
Medical Record Request Form – Third Party
Medical Record Request Form – Third Party
Medical Record Request Form - Third Party
THIRD PARTY (AGENCY / ATTORNEY / SCHOOL / OTHER)
Request for Documentation by Authorized Third Party
Requesting Organization
Organization Name
Contact Person
Phone
Email
Fax
Type of Document Requested
Attorney Letter / Legal Summary
Workers’ Compensation Form
FMLA Form
Disability Form
Assistance Program Form (EAP, employer, etc.)
School Form (with signed parental consent)
Work Form (with signed client consent)
Other
All Records
Ways to Complete Your Records Release Form
Download, Complete, and Upload
Complete the Form in Person
Click Here To
Download The HIPAA Form
HIPAA Authorization
Attach signed HIPAA Authorization for the release of the requested information.
Purpose of Request
Legal / Court
Insurance / Disability
Employment
School
Other
Processing & Fees Notice:
Standard turnaround: 7–10 business days
Fees may apply depending on complexity or external requirements
Requests may be delayed if incomplete or missing authorization
Legal Disclosures:
You may revoke this authorization in writing at any time. Released information may be re-disclosed by the recipient and may no longer be protected by HIPAA.
Only the minimum necessary information will be released in accordance with HIPAA.
Acknowledgements
I understand that this request cannot be processed without a valid HIPAA authorization, that only the minimum necessary information will be released, that processing time is 7–10 business days, and that the authorization may be revoked in writing at any time.
