Medical Records Request Form

Please complete the following form in its entirety when requesting medical records for a patient who has or is receiving care from Emerald Psychiatry.

Requestor Information

First Name

Last Name

Requestor Relationship to the patient

Requestor Emails address

Requestor Phone Number

Preferred Method of Contact (Please let us know the best way to reach you if we have questions about your request.)

Email Phine

Patient Information

First Name

Last Name

Patient Date of Birth

STARTING Date of Service being requested

ENDING Date of Service being requested

Type of records needed

File Upload

Release Of Information

Do you have a signed RELEASE OF INFORMATION on file? If not, please complete one and submit it along with this request.

RELEASE OF INFORMATION

Please also include PROOF OF IDENTIFICATION such as a picture of your driver’s license, proof of agency employment, a copy of a Power of Attorney, or other forms of Guardianship papers.

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