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 SummaryWorkers’ Compensation FormFMLA FormDisability FormAssistance Program Form (EAP, employer, etc.)School Form (with signed parental consent)Work Form (with signed client consent)OtherAll Records

Ways to Complete Your Records Release Form

Download, Complete, and UploadComplete the Form in Person

Purpose of Request
Legal / CourtInsurance / DisabilityEmploymentSchoolOther

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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 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.