Medical Record Request Form – Self (Client)

Request for Personal Letters or Forms

Date of Birth
Phone Number
Email
Type of Document Requested
Treatment Status LetterNarrative Summary LetterAccommodation Letter (school/work setting)FMLA FormDisability FormAssistance Program Form (EAP, HR, etc.)Work FormOtherAll Medical RecordMedical Records With A Date Range

Ways to Complete Your Records Release Form

Download, Complete, and UploadRequest the Form via Your Client PortalComplete the Form in Person

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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 may require verification of identity, that fees may apply depending on the type of form requested, that processing time is typically 7–10 business days, and that my authorization is voluntary and may be revoked at any time in writing.