--Please select Treatment location--
Main Office
(1001 14th St - Meridian, MS)
Medical Records Request Form
Patient Information
Patient Name *
Patient Address
Date of Birth *
Phone Number *
Requestor Information
Requestor Type *
Please Select
Attorney
Business Office (Internal)
Disability Determination Services
FMLA
Insurance (Payer) Request
Outside Audit
Patient
Patient - Send to Other Provider
Personal Representative (Legal Guardian / Pow
Personal Representative (Legal Guardian / Pow
Provider to Provider
Subpoena
Worker's Compensation
Requestor Name *
Requestor Organization
Requestor Address *
Email Address
Phone Number *
Fax Number
Release Information
Reason for Disclosure *
Your Reference Number
Authorization Expire Date *
Delivery Method *
Please Select
Secure Electronic Delivery
US Postal (May add 2-3 weeks for processing. Postage fees additional.)
Fax (May add 48 hours for processing. Fax fees additional.)
Note that any requests sent via US Postal may be delayed by 2 - 3 weeks.
There is no additional delivery fee for electronic delivery (there may be a retrieval fee), and records are made available in the secure Providerflow portal as soon as they are processed.
Requested Documents *
Include?
Document Category
Start Date
End Date
Lab Reports
Billing Reports
Radiology & Diagnostic Reports
Films/Images
Visit Notes
Correspondence & Outside Notes
Miscellaneous Admin
Other Clinical Documents
If start date is not selected records will be provided for the last 24 months
Comments
Please select any information that you wish to be excluded *
Exclude HIV / AIDS
Exclude Sexually Transmitted Disease
Exclude Mental Health Treatment
Exclude Drug / Alcohol Related
By submitting this request you acknowledge that payment is required prior to release of records. An invoice will be sent to the email or fax number provided above. Delivery times are from the date payment is received.
Submit