Physician Medical Records Request Patient Name: DOB: What you would like sent: Please check each item to be released Physicians Notes Lab Results CT Scan Operative Report All Medical Records (including CT Scan) Where and how you would like them sent: Name: How you would like them sent: Mailed Pick Up Email Faxed Address if mailed: PO Box: City: State: Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Email address, if emailed: Fax number, if faxed: Date of upcoming appointment: Date: 12/21/2024 Relationship to patient: Type your name: Prove you are human: Choose the cloud Choose the heart
