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Request Medical Records

Use this form to request a copy of your medical records or authorize us to release records to another provider, employer, attorney, or family member. Submissions are HIPAA-protected.

No account or portal signup required to submit this form.

Patient information

First name

Last name

Date of birth

Phone (optional)

Email (optional)

Records requested

From date (optional)

To date (optional)

What records do you need?

Purpose (optional)

Urgency

Send records to

Recipient name

Organization (optional)

Address (optional)

Phone (optional)

Fax (optional)

Email (optional)

Delivery method

Signature & consent

Type your full legal name

Drawn signature (optional)

Sign to consent to today's visit (optional)

I authorize Restore Wellness Psychiatry to release my records as described above. I understand this authorization is voluntary and I may revoke it in writing at any time. Records containing psychotherapy notes, HIV/AIDS, substance-use, or genetic information may require additional consent.